The recent report from The Nuffield Trust/The King’s Fund Where next for commissioning in the English NHS? (Smith et al 2010) describes the Health Service as reaching a ‘fork in the road’.
The report highlights the dilemma; should we can carry on with minor changes within existing commissioning arrangements or alternatively, should we push forward with a more radical approach to healthcare provision and commissioning.
The publication of the white paperEquality and excellence: Liberating the NHS (DoH 2010a) and its subsequent papers could not be more radical in its approach to healthcare provision and commissioning.
The Nuffield Trust/The King’s Fund publication makes a case that if practice based commissioners take responsibility for health outcomes it would assume proper control of service planning, development and the commissioning process.
It is unclear (at this moment in time) how, and who, is in the best position to support GP consortia to address the control and complexity of a ‘whole system’ approach to commissioning.
It is therefore understandable why many political commentators and organisations such as the BMA are highlighting the need to “look inside the NHS and to our professional body for support, rather than going elsewhere for advice.”
Addressing the complexity of the commissioning process should be undertaken on a large enough footprint in order to make a significant difference at both a local and population level. The white paper reinforces this essential ‘geographical’ point by highlighting the need for ‘the consortia to be of a sufficient size to manage financial risk and allow for accurate allocation’.
Furthermore, to make a significant impact towards achieving the five domains of the NHS Outcomes Framework (Liberating the NHS: Transparency in Outcomes – A Framework for the NHS 2010b) there needs to be, not only a large enough footprint to commission, but also a real understanding and responsibility to achieve the best and most cost-efficient outcomes.
Understanding, and justifying, the impact of any health care intervention has become increasingly necessary in the current economic climate and it is now widely accepted by various organisations and bodies (Department of Health 2008a, 2008b, 2009a, 2009b, 2010a, Office of Health Economics 2008, Devlin and Appleby 2010) that the way to understand and demonstrate the benefits is to measure the outcomes of what we do and the outcomes that are meaningful to people.
The PCT Procurement Guide for Health Services (DH 2010a) points to the importance of commissioners’ specifying detailed outcomes in the procurement process and argues that this is a commissioning priority. The policy goes further and asks ‘Can the commissioner define the outcomes required, service specification, funding model and prices up front within a procurement model’.
If commissioning organisations are to adopt this procurement guide then an outcome-based approach to commissioning that satisfies the requirements of the commissioning cycle is required. There are however, many outcome-based approaches to commissioning and contracting (Kerslake 2007, Pately and Slasberg 2007, Duignan 2007, Honoré et al 2004) and each approach is often tailored to the specific needs of the organisation (i.e. local government).
The Liverpool PCT Health Outcomes Team has developed an outcome-based approach to commissioning services that satisfies the requirements of the commissioning cycle. This process is known as the ABC approach to commissioning for outcomes. This unique framework has its foundations in the key elements of the commissioning cycle and therefore demonstrates how the cycle is utilised in practice.
The ABC model helps to develop, define, implement and monitor outcome measures and furthermore, provides evidence to the WCC assurance panel of what we do, how we do it, why we do it and the methodology behind it.
Apart from the model being flexible (in terms of the different types of services it can be used for) it also has important value as part of the criteria for our prioritising process as well as providing a process to support QIPP (DH 2010d) and the wider quality agenda.
The ABC approach to commissioning for outcomes focuses on;
- Assessment of need and delivery of the PCT’s strategic Aims
- The use of the Best evidence to inform what we do
- The review of Current practice and a formal Critique of the evidence.
- The Development of meaningful and measurable outcomes
- The Evaluation of services
- Ensuring that we Formulate the right data sets to assess the impact.
We believe that the ABC model (Figure 1) is the first outcome-based approach to commissioning that combines the commissioning cycle, the required national competencies for commissioning, evaluation and the principles of evidence-based care delivery.
Furthermore, a core value of this model, and a marked benefit, is to create a cohesive way of matrix working by linking staff and directorates together to attain a streamlined approach to commissioning and the achievement of the appropriate outcomes for the people we serve.
Not only does the ABC model provide an outcome-based commissioning process, it also supports the development of reliable, timely, valid and responsive outcomes at a service or patient level (Section D of the ABC model). In addition, the Health Outcomes Team has developed a systematic approach to identify the right outcomes for services, patients/clients and carers. We have created the Outcome Strategic Map to help commissioners and other healthcare professionals develop a strategic overview of the key improvement drivers (or services) that need to be commissioned in order to achieve the high level (population) or organisational outcomes (e.g. a reduction in cancermortality).
In utilising this model we firmly believe that we are prioritising our resources to demonstrate investing, instead of funding, and applying rigour to commissioning for outcomes (based on evidence) instead of what is believed to be ‘the right thing to do’. Currently, we are testing the ABC model against the PCT’s ‘value for money’ model to see if this disciplined framework can act as a catalyst to support commissioners in demonstrating value for money against clinical effectiveness (outcomes) and quality.
Many publications, and the recent White Paper, reinforce the message that commissioning organisations are required to become more outcome-focused and that they are required to measure outcomes for commissioned services. It is therefore crucial to be able to identify and develop the right outcome for the right service. What is not clear is how to choose the right outcome and how to commission for outcomes. We believe that our approach helps commissioners’ develop the right outcomes that will drive change and demonstrates to providers’ the clarity in how outcomes are chosen.
In developing outcomes we ask ourselves the following questions:
• What should be measured?
• How should it be measured?
• When should it be measured?
• What do we expect to happen?
In choosing the right outcome we consider the following question:
• What are the most powerful measures to detect a [clinically] significant change and are these a measure of therapeutic impact?
It is important to consider these questions in the context of the evidence-based literature, national standards and national guidelines (i.e. guidelines from the Royal Colleges’) and the wide ranging support from NICE (e.g. guidelines, commissioning guidance etc). If commissioners and providers apply these critical elements it should naturally describe what a quality service should look like.
As a commissioning organisation we are consistently moving forward in order to create rigour in what we do, effectiveness in our delivery and understanding in our quality of care. These elements are linked together to deliver for the areas of greatest need and to reduce inequalities. Future commissioning bodies will need to hold to account organisations and services for quality, cost and outcomes and it will be imperative to focus on these principles in order to deliver the key elements of the White Paper within the future financial constraints.
We believe by synthesising these principles and the elements of the ‘ABC’ model, we are providing a framework were key functions within the organisation are influencing and supporting each other in a structured way under the assurance and competency framework of world class commissioning. In addition, we have developed and implemented a dedicated education programme for commissioners, with an essential focus on quality and evidence within the outcome-based approach and this is now being delivered across Cheshire and Merseyside.
Finally, despite all the concerns over the future direction, structures and of how services will be commissioned, we believe that the ABC approach to commissioning for outcomes will stand firm during, and way beyond, these turbulent times.
Department of Health (2008a). Commissioning Assurance Handbook. Department of Health. London.
Department of Health (2009a). NHS 2010 -2015: from Good to Great. Preventative, People-centred, Productive. Department of Health. London.
Department of Health (2009b). The Operating Framework for 2010/11 for the NHS in England. Department of Health. London.
Department of Health (2010a). ‘Equality and excellence: Liberating the NHS’ Department of Health. London
Department of Health (2010b). Liberating the NHS: Transparency in Outcomes – A Framework for the NHS Department of Health. London
Department of Health (2010c). PCT Procurement Guide for Health Services. Department of Health. London
Devlin, N., Appleby, J. (2010). Getting the most out of PROMs: Putting health outcomes at the heart of NHS decision-making. The Kings Fund. London
Duignan, P. (2004). Intervention logic: How to Build Outcomes Hierarchy Diagrams Using the OH Diagramming Approach. Available at: http://www.strategicevaluation.info/se/documents/124pdff.html. [Accessed 9th April 2010].
Honoré, P., Simoes, J., Moonesinghe, R., Kirbey, H., Renner, M. (2004). Applying Principles for Outcome-based Contracting in a Public Health Program. Journal of Public Health Management Practice. 10(5); 451-457.
Kerslake, A. (2007). An approach to outcome-based commissioning and contracting Chapter Nine. [e-book] Care Services Improvement Partnership. Available at http://www.dhcarenetworks.org.uk/_library/Resources/BetterCommissioning/BetterCommissioning_advice/Chap9AKerslake.pdf. [Accessed 9th April 2009].
Office of Health Economics (2008). Report of the Office of Health Economics Commission on: NHS Outcomes, Performance and Productivity. London.
Pately, C., Slasberg, C. (2007). Implementing outcome-based commissioning. Journal of Care Services Management. Vol. 1. No.4; 353-361.
Smith, J., Curry, N., Mays, N., Dixon, J., (2010) Where next for commissioning in the English NHS?. The Nuffield Trust and The Kings Fund. London.
Stephen Callaghan is health outcomes manager at Liverpool Primary Care Trust