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The flipside of commissioning


8 December 2014

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The issue of cuts, value for money and quality is dominating the current healthcare agenda, but not much is heard about decommissioning which often presents an opportunity to positively transform services. Uniform top slicing of budgets or indiscriminate cost cutting can leave GP commissioners feeling exposed and may simply displace or even increase costs. However, good decommissioning can improve value for money by closing ineffective and inefficient services, and so can drive up the overall quality and standard of care. Here’s how it’s done.

Understand what you are currently commissioning
Often GPs at all levels of the clinical commissioning group (CCG) will not have been involved in former Primary Care Trust (PCT) commissioning meetings and won’t have a good idea of what agreements were put in place with local providers. As a first step lead GPs will need to establish in detail what they are paying for and so should start with a stock-take of what providers (both public and private) they are working with, and what contracts are in place, including information on their duration, clauses, stated activity levels, key performance indicators and cost. They will also want to establish at this stage the funding and payment models in place, what penalties have been written into the contracts for under/overperformance and how contract performance is being managed. However, the contracted arrangements may not tell the whole story – it is also important to understand what informal arrangements may be in place per providers.
It is crucial to know the existing patterns of use, gaps and duplication of clinical services. GP commissioners should have a clear understanding of service costs, benefits and savings and the potential future costs and benefits. It is not unknown for some providers to struggle to provide GP commissioners with accurate figures on activity – a huge problem that continues to need urgent attention. A number of business intelligence solutions now available to CCGs have the capability to display functional and outcomes-based dashboards with amalgamated primary care, secondary care, community care and social care data. This is an important consideration, particularly where integration transformation priorities are promoting the use of the NHS number across health and social care.
 
Understanding the patient needs 
GP commissioners and CCGs must have a clear understanding of the needs of local patients and groups. A strong focus on patients will ensure outcomes are met effectively and services are relevant to the locality in the long term. It is also important to consider how GP commissioners engage with patients, particularly hard-to-reach groups, where using an equality impact assessment as part of a wider service change assurance process should support thinking and potential acceptable solutions when making decommissioning decisions. Specific services – or group of users of a more detailed service – may require a more specific needs assessment. Similarly, some groups of users can have particularly complex needs that may require more analysis and evidence to understand the complexity of good service provision.
As good practice, all needs assessments should involve patients, service providers and other key stakeholders, especially where a service review is taking place after a long period of time has elapsed since any previous needs assessment. Consultation with patients can be a quick and effective way of gauging any changes in need or unmet need, gaps and/or duplication and in assessing future patterns of service provision. Such consultation can help commissioners understand the current failings or good practice in services as experienced by those using them first hand.
Once the decision has been made to decommission a service or to recommission a different service, attention has to be paid to decommissioning decisions that are often made due to changing policy priorities in health and social care. At this early stage, it is important for commissioners to identify the key policy imperatives (as set out in national policy or local strategic plans) and assess how these may have changed against current provision. GP commissioners need to consider how to prioritise preventive services to protect long-term outcomes and reduce the need for other, possibly more expensive interventionist services. Effective commissioning decisions, and hence decommissioning decisions, should have a sound evidence base, such as the joint strategic needs assessment (JSNA) which provides an excellent opportunity to look at integrated health and social care needs. This also needs to be put alongside the latest evidence in relation to clinical services for conditions and proposals made using best evidence. 
 
Identify services that may not be providing value for money
Understanding variation in service provision is critical. GP commissioners need to look at services that ‘leap out from the stock take and needs analysis’ as areas of potential concern and should evaluate services in terms of quality and outcomes, how well they are meeting the expectations of patients and the use of innovation and technology to ensure the best service within a given financial envelope. Services that are of concern to local people or do not provide the best clinically evidenced service could be potential candidates for decommissioning.
The health sector is under increasing pressure to reduce costs and innovate. New solutions and services should be evaluated if they seem to be expensive in their cost per activity. The scale of the cost reduction means looking beyond immediate short-term efficiencies and thinking more radically of ways to reduce costs over the long term by looking at innovative care delivered closer to patients home, joint working with local authorities on integrated care solutions and focusing on outcomes. The integration agenda is progressing at pace, and GP commissioners should understand their integration priorities to be meaningful partners with other agencies.  
However it’s vital that decommissioning is thought through, as a lack of planning could leave CCGs simply displacing costs or even exposed to higher costs due to unforeseen consequences. However, commissioners must avoid manipulating data or using needs assessments in a selective way to justify decommissioning decisions – CCGs need to be absolutely transparent and open to ensure public confidence in the decision making process.  
 
Understand the local provider market
Understanding the local provider market is key at this stage of the process of potentially decommissioning a service. It is important to understand how current services are actually delivered on the ground and by whom. If commissioners are considering re-commissioning or decommissioning a service or significantly altering a specification, they must be sure that there is the capacity or expertise in the provider market to respond to this. Commissioning support units or other providers of support can understand the ways in which to engage with the market through appropriate use of prior information notices, market provider workshops, service adverts as well as ‘informal days’. CCGs need to innovate and think about the mechanisms that might attract more providers in terms of contract length, the procurement process and funding levers while ensuring they remain within the procurement law.  
Commissioners need to be aware of the effective and rapid routes to market, promoted through national policy, service frameworks, guidance and implementation support packs, particularly around any qualified provider (AQP) opportunities. Services that have been subject to AQP scrutiny and re-commissioning include service areas such as continence, back and neck pain, diagnostic tests, adult hearing, podiatry and access to wheelchairs. It gives commissioners an opportunity to look at current provision of services, including quality, performance and value for money and opens up the market to other providers to ensure patients have a greater range of choices at comparable cost. However, the services must be specified to meet users’ needs and must be capable of being delivered by providers.
By understanding the current services in all its complexity the GP commissioners are able to gain a picture of what works and what does not. A part of this is to have a good understanding of how services are actually being delivered against the original specification. Services may have changed over time and no longer be in line with the original terms of the contract. This may be due to users’ needs, delivery management issues by the provider, or inadequate monitoring by commissioners across the whole range of contracts for the specific disease area. Poor monitoring can create a disjunction between what service provision is being carried out and needed by patients and local population and what is commissioned, re-commissioned  or decommissioned strategically.  This can lead to ‘ivory tower decommissioning’ – especially when commissioners are dealing with hundreds of contracts at any one time. Commissioners need to look at contract monitoring data, service review information and user feedback but also to ask providers for their assessment of the impact of the service in terms of outcomes.
Providers may be able to add significant knowledge to the decommissioning process through an understanding of the needs, quality and scope of services and potential for innovation and improvement. Providers can bring user needs to the fore and a good relationship with them is an opportunity to draw on their knowledge and market intelligence.
 
Understand the impact of decommissioning decisions 
Impact analysis is an important tool with decommissioning a service and there is a need to ensure a long-term benefit on the outcomes for patients and the local health economy – and may strengthen the case for change.  
CCGs should evaluate the impact, intended or unintended on users, providers and local stakeholders when decommissioning a service. Good commissioning should involve the longer-term development of providers and markets to ensure value for money via adequate levels of competition, choice and quality, which should include the third sector. Mitigating any adverse effects of decommissioning may require some element of capacity building especially with the third sector providers, such as giving guidance to providers on their business processes, governance and so on, or a short extension of a grant/contract to allow providers to look into alternative sources of funding for sustainability. 
In addition there can be workforce considerations to ending of contracts. It is important to get professional advice early on in the process especially in relation to issues such as transfers of undertakings (TUPE).
 
Are there other options to decommissioning?
GP commissioners also need to understand any alternatives to decommissioning, particularly when potentially decommissioning a service during a contract period. A contract review meeting may be helpful in working with providers to optimise quality and cost effectiveness through agreed contract variations, joint exploration of commissioning opportunities and challenges, and supporting service development and improvement. 
Once the need for a disease specific contract review meeting has been identified, commissioners will need to focus on a number of areas including quality, technology and value for money with the provider. An example of where this has been effective is in relation to medical equipment and devices.  Many commissioners have used high upfront Capex to purchase equipment which is wasted in storage or becomes quickly out-of-date. There are now many new providers to the market who are offering a whole new ‘pay-as-you-use’ model that is both scalable and flexible or a “risk share” agreement where payment for equipment and devices is made only when agreed outcomes are achieved. Commissioners should be challenging existing contracts with providers when new, innovative models promise to provide better value and more effective results and better outcomes. A chronic obstructive pulmonary disorder (COPD) patient costing the PCT £4,000 per annum could be transferred to a pay-as-you-go model that might cost as little as £20 per patient per month.
 
Ensure robust stakeholder engagement
A vital part of the decommissioning process is open, honest, regular and transparent engagement and consultation with stakeholders combined with clear and transparent decision-making processes. 
There should be clear and objective reasons for the decommissioning of a service based on assessment of the current providers’ performance, value for money and the need to improve services for patients. Decommissioning must result in demonstrable benefit, such as higher quality of care or value for money. Consensus on why service change is needed ensures all stakeholders own the process and reduces mistrust from patients and providers alike. However, commissioners need to be sensitive to the impact of decisions on service providers and users, and to manage the uncertainty and fear that can arise when decommissioning is being considered. To achieve this, it is crucial to:
Not be afraid of having difficult conversations and dialogue with providers, patients and local stakeholders.
Admit uncertainty.
Accept the anger of users, providers and the wider community and indeed some individuals GPs to what may be a much-loved service.

Listen and accept what is being said and don’t be defensive on the need for change.
Adopt a consistent and flexible approach to communication, trying to tailor it to the individual or group as appropriate; it is important to have a media strategy in place.

Avoid being driven by political or personal beliefs, but focus on patients’ wellbeing and providing the best possible care while seeking value for money.

Be honest – about the situation, the rationale for decommissioning, and the process to be undertaken.

Fear of losing a service, or having it altered, can be difficult for all concerned and commissioners should handle the process with empathy and sensitivity. Uncertainty and lack of information in the early stages of the process can heighten this stress and commissioners should be available to answer any questions that stakeholders may have.

 As part of the process it may be helpful to identify questions that stakeholders are likely to ask, and agree appropriate answers (including checking these answers with legal and other relevant advisers). 

Once the intention to decommission or to recommissioning becomes more widely known commissioners may need to deal with questions and complaints from a wider group of stakeholders who are unlikely to have been involved in the planning process. 
It is important to ensure that relevant and publicly available documentation is accessible to providers, stakeholders and others if unnecessary suspicion or complaint is to be avoided. 
Aligned to this it may helpful if a code of conduct is agreed between the commissioning group and the local providers – governing the behaviours of commissioners and providers during decommissioning, especially if it is likely to take more than a long period of time to complete the process.

In our experience being open and taking an honest approach has helped reduce anxiety, trying to understand better the position and indeed develop a better and proactive relationship with the local populations, local councillors/politicians, and the media. 
 
Put in place good governance 
A clear decision-making process and governance structure allows all stakeholders to understand roles and responsibilities. Commissioners must provide evidence that all contractual performance processes have been complied with, where performance is cited as the reason to decommission or re-procure and this must be allied to a robust risk assessment process. At a minimum commissioners need to give six months’ notice. However most respondents advocate longer if possible and certainly longer where there is a complex case (for example: a large TUPE transfer; or issues relating to property and asset implications).
 Another key consideration is the need to align decommissioning decisions and processes better with the financial and contractual cycles. Commissioners should ensure that decisions are made early on, and are not driven just by the need to decommission by the end of the financial year. Good forward and budget planning should mean that decisions can be made earlier.
 
Ensure you comply with public contract and competition rules
CCGs need to adhere to legislation that governs the award of contracts by public bodies, including the Public Contracts Regulations 2006, and will need to satisfy the obligations of transparency, equal treatment and non-discrimination. Furthermore, the NHS (Procurement, Patient Choice and Competition – No. 20) Regulations 2013 impose additional procurement obligations on CCGs and particularly in using procurement to secure improved service quality and efficiency. CCGs will also need to comply with regulations under section 75 of the Health and Social Care Act, which will place requirements on commissioners to ensure that they adhere to good practice in relation to procurement, do not engage in anti-competitive behaviour, and protect and promote the right of patients to make choices about their healthcare. 

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