If the full potential of GP commissioning is to be realised, commissioners must understand, embrace and harness transformational technologies at the earliest opportunity, says NHS North West director of commissioning development Joe Rafferty.

It has often been suggested that successful reform of the NHS depends on the ability to deliver five major component changes: Harnessing the patient and users more generally; relocating care delivery; improving management and measurement; integrating health and social care budgeting and commissioning; and embracing and exploiting transformational technologies.

To date, guidance and debate about GP commissioning has recognised commissioners will have an important role to play in relation to the first four of these - for example much attention has been given to patient engagement (first change above); to the design and implementation of care pathways (second change); the need for commissioners to attend to leadership development and data management capabilities (third change); and to the important interface GP commissioners will have with local government commissioners (fourth change).

However there has been little debate about how GP commissioners might exploit transformational technologies to reform and improve the NHS. This paper attempts to address this oversight and suggest what role GP commissioners might have in exploiting the reform potential of these technologies.

Focusing on the customer’s customer

The Centre for Medicare and Medicaid Services (CMS) is the largest public purchaser of health care in the United States. It purchases the great majority of the health care delivered to the over-65 and indigent populations (more than 80m people). Traditionally, CMS has fulfilled the role of what might be thought of as the ‘orthodox’ purchaser. It negotiated and agreed prices with providers for different services and then, over time, introduced a number of constraints designed, for example, to discourage the routine provision of cost-ineffective interventions and/or to cap volumes. CMS’s relationship with its providers was therefore “hands off” – it focused on what and how much it wanted to purchase and left the provider free to decide how best to deliver those services.

In 2003-04 however the relationship between CMS and its providers began to change. CMS became aware of the work of Premier Inc documenting how a focus on clinical quality in the form of agreed “best practices” and a small number of outcome measures, led to significant decreases in patient mortality, readmission rates, complications, length of bed stay, and in costs.

CMS therefore offered enhanced reimbursement rates to those providers who agreed to adopt and monitor the impact of these practices. This change rapidly resulted in similar improvements in service quality and outcomes and to lower costs.

It is now compulsory practice in all hospitals funded by CMS. This same approach to service quality was later adopted in NHS North West and has led to similar improvements.

There is a striking difference in CMS’s orthodox purchasing role and its latter role as purchaser and ‘quality watch dog’:

While CMS originally invested almost all its effort in trying to fashion workable and acceptable relationships with its principal “customers” – the providers - it later discovered that much of what it wished to achieve required a complementary focus on the customer’s relationship with their customer - i.e. between provider and patient.

As a consequence, its providers became preoccupied with the introduction of best clinical practices. It should be clear, however, that it is far from easy for organisations such as CMS to successfully cause this shift in focus.

If not carefully handled it can easily mutate into an unwelcome and counterproductive interference in the internal affairs of providers – as well as in the relationship between clinicians and their patients.

In contrast, if handled sensitively, this shift in focus can lead to higher quality care, improved outcomes and lower costs.

Embracing transformational technologies: is there a role for commissioners?

In relation to transformational technologies, it is possible to point to a number that have the potential to transform commissioning.

Examples include the internet, wireless and GPS technology, handheld devices, voice and image recognition technology, and telemedicine.

They often enable organisations such as GPs and GP commissioners to unobtrusively, helpfully and effectively focus on the relationship between providers and their patients. This, in turn, can lead to increased patient safety, higher quality care and lower costs.

Examples include:

  • Clinical process improvement at the point of care: Nurses in a number of US hospitals are routinely utilising handhelds based on iPod Touch technology to improve bedside medicines administration; receive best practice alerts in real time; access clinical decision support; and in some cases to engage patients in the coordination of their care. It has resulted in a significant reduction in clinical and medication errors; increased nurse productivity and job satisfaction; and reduced costs.
  • Engaging patients and potential patients in real time: In a number of countries systems are in use that are typically built around online services and telemedicine brought to a patient’s or prospective patient’s home (or wherever they happen to be, via mobile communications).This results in a reduction in demand for hospital and community care services, reductions in mortality and lower costs.
  • Amplifying the general practitioner’s system intermediary role: GPs and other primary care clinicians sit at the centre of connections between clinicians, patients, the public and social care. A number of technology providers are offering services and devices for GPs to fulfil this intermediary role more efficiently and effectively. Typically these involve the use of websites for interaction between clinicians and patients and patients with each other, for self care, and for engaging patients and the public in debate, opinion polling and feedback. Organisations offering what are becoming known as “health 2.0 services”, and their users, are making the very plausible claim that they bring about reduced bureaucracy, lower costs and more responsive and appropriate care.

These examples all seek to modify the relationship between clinicians (and/or care givers) and patients (and/or potential patients) in order to reduce costs and improve the quality of care.

They also all have the potential to fundamentally transform commissioning practice.

GP commissioners might require providers to use technologies which improve care and reduce cost or allow patients to be managed in remote settings; or require their peers to use technologies which allow them to enhance their role as system intermediaries.

For commissioners to embrace and successfully exploit transformational technologies in this way however will not be easy. It will necessitate a shift away from the view that commissioners stand back and purchase services on behalf of their populations, toward a view that commissioning is about shaping and re-designing services so that they better address the needs of their populations.

This is important – the first view tends to regard technology as simply a tool to facilitate more adroit commissioning, while the latter sees it as a lever for forging closer and more productive partnerships with providers and populations.

Commissioners are not only interested in the cost of the services they are buying - but also in quality, safety and outcomes. Payers have recognised it is only by focusing on the needs, preferences and behaviour of patients that the full potential of commissioning can be realised. Technology provides a very swift and immediate means both for understanding and shaping these; and re-engineering the relationship between users and services.

Commissioners cannot be indifferent to these technologies. Instead, it is essential they understand, embrace and harness them at the earliest opportunity. If the full potential of GP commissioning is to be realised in practice, there is no alternative.