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Commissioning top 10

Commissioning top 10

Insight: commissioning

Chris Naylor
Policy Researcher, The King's Fund


NHS commissioners have the opportunity to transform the way healthcare is provided. As responsibilities are transferred to commissioning consortia or clinical commissioning groups, GPs and other professionals involved will be inheriting a system which faces daunting challenges. By rising to these challenges, they can help secure a sustainable healthcare system able to meet the needs of future generations.

Chris Naylor
Policy Researcher, The King's Fund


NHS commissioners have the opportunity to transform the way healthcare is provided. As responsibilities are transferred to commissioning consortia or clinical commissioning groups, GPs and other professionals involved will be inheriting a system which faces daunting challenges. By rising to these challenges, they can help secure a sustainable healthcare system able to meet the needs of future generations.

The ageing population and increased prevalence of chronic diseases require a strong re-orientation to deliver integrated care and a move away from the current emphasis on acute and episodic care towards prevention, self-care and more consistent standards of primary care. The alternative is significant unmet need, increasing threats to the quality of care and, ultimately, a threat to the sustainability of a universal, comprehensive tax-funded healthcare system.

The King's Fund's report, Transforming our healthcare system: Ten priorities for commissioners, describes 10 areas in which action will be needed. The emphasis is on proactive management of chronic disease, empowerment of patients and shared-decision making, taking a population-based approach to commissioning, and encouraging the development of more integrated models of care. The 10 priorities should allow commissioners to improve patient experience and clinical outcomes, while reducing costs.

1. Active support for self-management
With appropriate support, most people with long-term conditions can manage their own condition. Self-management techniques can improve the patient experience and, in some cases, have been found to improve clinical outcomes and reduce unplanned hospital admissions. There are a number of well-established self-management programmes for commissioners to draw on, such as the Diabetes Education and Self-Management for Ongoing and Newly Diagnosed (DESMOND) programme introduced widely across the NHS for people with diabetes.

2. Primary prevention
The financial sustainability of the NHS will depend on more systematic primary prevention to reduce the overall burden of disease in the population. Around 80% of cases of heart disease, stroke and type 2 diabetes could be avoided through lifestyle changes. Primary prevention can be highly cost-effective, with prevention in childhood demonstrating particularly large returns on investment. Evidence-based interventions range from opportunistic lifestyle advice to systematic community interventions to reduce childhood obesity.

3. Secondary prevention
There is scope to be more proactive in detecting the early stages of disease and intervening before full symptoms develop. Widespread variation exists in how effectively this is done – evidence suggests that it is an area where the 'inverse care law' applies, with those in greatest need being least likely to benefit. Addressing this variation and encouraging practices to adopt more systematic approaches, such as disease registers, case-finding and risk stratification tools, should be a priority for commissioners.

4. Managing ambulatory care sensitive conditions
A significant proportion of all acute hospital activity is related to ambulatory care sensitive (ACS) conditions such as congestive heart failure, diabetes, asthma, angina, epilepsy and hypertension. Actively managing these patients in primary care through vaccination, better self-management, disease-management, case-management or lifestyle interventions can prevent acute exacerbations and reduce the need for emergency hospital admission. The NHS Institute for Innovation and Improvement estimates that commissioners could save up to £250m across England solely by spreading existing good practice in this area.

5. Integrating mental and physical healthcare
There is a pressing need to improve the way patients with mental and physical health needs are managed – in particular, those with common mental health problems (such as depression or anxiety), alongside a physical long-term condition. There is a strong association between mental and physical ill health, and co-morbid mental health problems have a significant impact on the costs related to the management of long-term conditions. Specific actions for commissioners include encouraging more systematic coding and recording of mental health needs in primary care; developing shared care arrangements between primary and secondary care; supporting the work of psychological therapy services; and commissioning new forms of liaison psychiatry services in acute hospitals, care homes and elsewhere.

6. Care co-ordination through integrated health and social care teams
Co-ordination of care across settings and over time is currently poor, particularly for those patients with the most complex needs. Improving this can have a significant effect on the quality of life of frail older people and those with multiple long-term conditions. Commissioners will achieve most with a multi-component approach; for example, by encouraging a move to multi-professional teams; joint care planning and co-ordinated assessments of care needs; and a new model for primary care with GPs acting as system navigators and retaining responsibility for patients throughout the care pathway.

7. Improving primary care management of end-of-life care
The cost of caring for people at the end of their lives is estimated to run into billions of pounds and, at present, too many patients, families and carers receive a fragmented, poor-quality service. Primary care has an important role to play in improving the co-ordination of care, quality of communication, and provision of bereavement care. Commissioners need to ensure that a range of services are available across the care pathway, including facilitation of discharge from the acute setting; rapid response services during periods out of hospital; and centralised co-ordination of care provision in the community.

8. Effective medicines management
Prescribing costs are rising at a relentless rate; between one-third and one-half of all medications prescribed for long-term conditions are not taken as recommended; errors occur in up to 11% of prescriptions; and around 7% of all hospital admissions have been associated with adverse drug reactions. Improved medicines management, therefore, represents a major 'quick win' for commissioners in terms of both cost and clinical outcomes. There are a number of techniques available that GPs will be in a prime position to implement, including medication reviews, use of IT and decision-support tools and a range of pharmacist and nurse-led interventions.

9. Managing elective activity – referral quality
There is significant scope to improve the quality of referrals from primary care, and by doing so to manage elective activity more effectively. GPs make more than 9 million referrals to hospitals for elective care each year, triggering an expenditure of £15bn. There are wide variations in referral behaviour and evidence that referral quality could be improved; for example, in terms of the destination to which referrals are directed and the content of referral letters. Commissioners should encourage GPs to establish systems for reviewing and auditing referrals with a view to benchmarking against other practices. Approaches based on peer review and audit are recommended over the establishment of referral management centres.

10. Managing emergency activity – urgent care
Developing more integrated urgent care services is our final priority for commissioners. It is an area where services are currently often highly fragmented, and where there is poor sharing of information – a cause of many significant failures of care. It is also an area where there has been significant growth in expenditure, with emergency admissions in England rising by 12% between 2004/5 and 2008/9. To tackle this, commissioners will need to investigate patient flows and build new systems to improve co-ordination of care between different providers. An important element of this will be preparing for local implementation of the new NHS 111 service for care in urgent but non-life-threatening situations, to be rolled out in 2013.

The 10 priorities provide an action plan for any new commissioning bodies and GP practices to transform the health of their local population. The potential gains for health outcomes, patient experience and cost savings are considerable, but implementation will not be straightforward due to the scale of the change management task.

A major focus of the 10 priorities is on developing more integrated systems of care. The challenge of an ageing population with rising rates of long-term conditions demands that we develop new ways of working in which services are co-ordinated more effectively and professionals work together to meet patients' needs. The government's reforms to the health and social care system must ensure that incentives for integration are maintained and strengthened, as laid out in the King's Fund's official response to the legislative pause, 'Where next for the NHS reforms? The case for integrated care'.

While it is relatively straightforward to impart knowledge about what to change, it is much harder to create the culture and enthusiasm required to deliver change, particularly when working across organisational boundaries.

The potential strength of GPs' engagement in commissioning is that their clinical foundation is a step towards creating the necessary culture; but if they are to take on real budgets they will need to invest heavily in developing strong commissioning organisations and good working relationships across the health system. Only then will it be possible to make the most of the opportunity that the reforms to the commissioning system present.

This article is based on the report Transforming our healthcare system: Ten priorities for commissioners by Candace Imison, 
Chris Naylor, Nick Goodwin, David Buck, Natasha Curry, Rachael Addicott and Paul Zollinger-Read, available from:


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