The publication of the Commissioning framework for health and well being is a welcome reminder that 13 months ago the government published white paper Our Health, Our Care, Our Say. For many of us it is a long-awaited statement about the future direction for the 90 per cent of NHS activity that takes place outside hospital and, in particular, for our relationship with social care.
The framework underlines the importance of a strong information and evidence base to underpin commissioning. It proposes a new duty on primary care trusts and local authorities to produce a joint strategic needs assessment to drive commissioner priorities and actions.
Mining multi-agency data produces interesting new patterns of association. For instance, life-expectancy in men in Birmingham is poorest in those areas with high death rates from respiratory disease, poor literacy, low educational attainment, high unemployment, low income, high violent crime and low car ownership. In women, it is concentrated in areas characterised by just two measures: high levels of chronic illness and low car ownership.
This kind of cross-matching can challenge commonly held assumptions about priority areas. Assuming that the index of multiple deprivation is a proxy for poor health identifies the five 'worst' wards in Birmingham, but three of these change when we identify the five with the greatest concentration of risk of early death.
This population-based information provides a different perspective to utilisation information. Typically, our concern with utilisation data is to identify those at highest risk of high cost, whereas the population approach begs us to consider shifting the mean and having an impact on far greater numbers of people, still with the intention of achieving lower costs and better outcomes.
By concentrating more on improving every child's attainment in literacy and numeracy, this may reduce the number of school-leavers who can neither read nor write. This is turn may reduce the numbers at risk of low income or unemployment and low self esteem, with all the associated risks for health status.
Prevention versus attempted rescue
Alternatively, such a strategy may abandon those in most need to facilitate even better attainment from those who would succeed anyway - the familiar healthcare debate about investment in prevention versus attempted rescue.
The framework creates the potential for the NHS, through practice-based commissioning, to invest directly into social care. This also raises issues both practical and philosophical.
Most metropolitan boroughs that hosted more than one PCT struggled with boundaries and differences in policy and practice at the level of 100,000-plus population. How will they have the capacity to respond to individual practices serving populations of 1,500-15,000? This would be easier if practice populations fell neatly within geographical boundaries of neighbourhoods or wards. Unfortunately, the language of 'practice-based commissioning' has reinforced the tendency of GPs to resist attempts to corral them into locality clusters.
This alignment at practice level perhaps also betrays a simplistic assumption that practice-based commissioning and direct payments are somehow parallel and aligned policy initiatives. The campaign for direct payments came out of the advocacy movement and a commitment to achieve the best possible service for each individual service user. Practice-based commissioning is the latest of a series of initiatives to promote awareness among GPs that every clinical decision has a financial consequence. The one emphasises the rights of the individual regardless of cost, the other attempts to consider the population consequences of individual decision and, critics would argue, is based on a commitment to the needs of the many outweighing those of the few.
Where the framework breaks new ground is in addressing the links between employment and health, and in the role of NHS and local government as major employers. The themes identified are not in themselves revolutionary; delivering services to help people stay in or return to work, recruiting locally and from disadvantaged groups, redeployment of staff to support them staying in work, and investing in providers that pay attention to the health of their staff and communities. However, it is unusual for a mainstream Department of Health policy document to devote a whole chapter to an agenda more usually seen as the responsibility of the Department of Work and Pensions. Given the role of the NHS and social care as often the major employers within disadvantaged communities, this is a useful reminder that our own recruitment and development practices may play a major role in delivering either regeneration or status quo.
The framework, then, is a welcome and timely reminder that most of what we do in the NHS makes only a limited difference to health outcome and status. It identifies how we could be using commissioning to maximise this impact.
We know that what is measured becomes what is important, particularly within the target-driven culture of the NHS. Having broken the silence on the world outside the hospital, it will be interesting to see whether our progress is now given the same attention as, for instance, the delivery of a 90-second improvement in ambulance call response times, where DoH commissioning director Duncan Selbie has already raised expectations of new investment at around£600,000-plus per PCT.
In this context it is worrying that the document signals local accountability for delivery of the health and well-being agenda -presumably leaving the DoH free to monitor what it perceives as the really important stuff. -
Sophia Christie is chief executive of Birmingham East and North PCT.