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Insight: Pathway of improvement

Insight: Pathway of improvement
4 June 2014



There are potential benefits of the commissioning pathway approach which is being taken by some CCGs.
Clinical commissioning groups (CCGs) are now just over one year old. In some cases their progress in such a short time has been remarkable. One area where a small, but growing, number of CCGs are making transformational change is in commissioning pathways for outcomes. This is major change compared to the more traditional commissioning approach of the majority of CCGs, which involves ‘contracting’ with secondary care. It is by no means a criticism and mirrors a similar approach by primary care trusts (PCTs) in the past. The big difference is that CCGs’ management resources are relatively light by comparison.
During a recent meeting with a CCG director, the major problems facing her in A&E at the local hospital came up in conversation. As the story unfolded it became clear that this commissioner was spending at least 50% of her time micro-managing the running of the interface with A&E – with the willing participation of the hospital. This involved linking into community service providers, the Local Authority and the out-of-hours provider. Of course these circumstances are not unique, but the real danger CCG directors face is immersing themselves in the detail management issues of numerous providers, rather than setting the commissioning outcomes that are desired and leaving the provider to use their initiative.
Commissioning a single provider to take responsibility, in this case, for the whole urgent care pathway would have been one way to achieve this aim.
What benefits might it bring?
The beauty of commissioning one provider is that risk is better managed. So, instead of dealing with multiple points of view where sometimes unnecessary debate prevails, the CCG deals with a single provider who then manages the risk of working with multiple providers. With this approach the CCG is also able to set overarching outcome requirements and the single provider is then held to account. As a result, outcomes can be more tightly managed. Costs and risk are better handled as the single provider is awarded a budget that encompasses the entire pathway. The financial risk then falls to the single provider, not the CCG.
This, of course, allows CCGs to focus more time – and greater attention – on its core commissioning role of setting providers challenging outcomes to improve local population health. 
How is it achieved?
CCGs can take a number of routes to achieve this aim. A common approach initially has been to set out a detailed specification of requirements and outcomes and go to the market. A number of CCGs have used this approach for musculoskeletal pathway delivery. However, the approach does potentially have some flaws. 
Firstly, it assumes that the CCG has a deep understanding of the ‘best in class’ solutions. Secondly, there is a presumption that the CCG will be clear on the delivery models of the future. I believe that the NHS is much more open to learning from others than in the past. However, the sheer pressure of day-to-day working in a CCG makes it difficult to be really on top of trends and latest thinking. 
A better way?
A better route is through a ‘competitive dialogue approach’. This takes longer but has the attraction of bringing innovation and ‘future proofing’ into the solution. KPMG, for example, are working with a group of CCGs in the South of the UK to carry out a process of this nature for an urgent care pathway. It will result in the appointment of a single provider to take responsibility for managing a number of other providers who supply care to patients requiring urgent attention. This pathway will be community and primary care based and links all services up to the A&E door. 
The approach we are taking with the group of CCGs is five-fold. We are working with the CCGs to set out the high level outcomes that they want to achieve for urgent care. This can be about eliminating avoidable hospital admissions through to better use of risk stratification to target patients who would benefit from early interventions.
It involves going to a broad market with these outcomes and asking for responses on how they would meet these challenges. Crucially the market is encouraged to come back to the CCGs with innovative responses and to highlight gaps in the outcome requirements. This means that the CCGs benefit from the whole market and can challenge their own thinking about ‘what good looks like’.
The responses are then whittled down to a small number of credible providers through an assessment process. Then, using intelligence provided by the market, the CCG is able to refine their requirements into a more detailed tender process which is sent to the small number of providers. 
Finally, the process is used to identify one or two providers to enter into detailed discussions and eventually detailed negotiation to appoint a single provider for the urgent care pathway covering a population of many thousands.
What are the potential challenges of this approach?
It may be an ordered process, but it takes time. A typical competitive dialogue can take nine to 12 months. This is perhaps three to six months longer than a straightforward tender process can take. The CCG may believe that it already knows the key outcomes it requires and see the additional time (and opportunity cost) unnecessary.
At the outset it can be tricky aligning clinicians across the CCGs to agree the same high-level outcomes. This can be an issue where there may be potential conflicts of interest with some clinicians having an interest in, say, a local provider who may wish to bid for the work. 
The key outcome is that the CCGs will have a more robust and innovative set solutions managed by a single provider, thereby offsetting elements of risk.
Another key outcome is that the CCG will be a more confident commissioner having been through a detailed process where their thinking has been challenged and improved. This should have a tangible impact on other commissioning decisions.
Where does it leave the CCG?
CCGs are leading the approach to transform commissioning by using innovative techniques to improve outcomes. As commissioners increasingly focus on the ‘whole patient’ the role of care pathways will come to the fore. CCGs can spread risk, manage costs and build innovation into solutions using the competitive dialogue approach. This is particularly suited to pathways where the solution is not fully known. At present the number of CCGs taking this approach is small. In the near future this approach will be the norm.
Gary Belfield is the head of commissioning and associate partner 
at KPMG.

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