Commissioning is entering the ‘value era’ where care is bought based on the population’s needs and the perceived value to the patient
Commissioning is entering the ‘value era’ where care is bought based on the population’s needs and the perceived value to the patient
For the last 10 years the focus of the health service has been on the quality, safety and compassion of the services delivered to patients. Running throughout this, and with increased emphasis following the publication of the Five Year Forward View in October 2014, is the need for efficiency; namely improving quality and safety to get better outcomes at a lower cost. If you are a clinician or clinical director these would be your responsibilities and objectives. So what then is the aim of commissioning?
Since its inception as a national quality, innovation, productivity, prevention (QIPP) programme in 2010, the Right Care programme (now a programme of NHS England) has sought to challenge the fundamental planning processes where historical activity is trusted to make financial allocations to traditional care programmes with established providers. Right Care set out to destabilise that complacency by asking new questions,
for example:
- How many diabetics are there in the population served by this CCG?
- How much do we spend on diabetes?
- For what outcome?
- How do we, in this clinical commissioning group (CCG), compare with our demographic peers in spend and outcome?
The opportunities offered by clinical commissioning may lead to asking and defining these questions, but clinical commissioners often do not know the answer, although they may know to the penny the cost of their contract with the local district general hospital (DGH) or be able to recite the figure of their deficit.
These questions are important if the NHS is to make a shift from traditional planning and contracting around organisations and clinical processes, to one that is focused on value and doing the right things. The time for clinical commissioning has arrived as we are entering the ‘value era’, in which the new CCGs can use a population and patient view of value to increase health outcomes for both their populations and individual patients.
The simplest way to think of value is from an economic perspective. The word value is, like many English words, slippery to define and has different meanings to different people. In the plural, ‘values’, the word has a moral meaning. For example, “we value diversity and equality”. In the singular, however, the meaning is economic. The Right Care approach identifies three types of value:
- Allocative value.
- Technical value, which is similar to efficiency.
- Personalised value.
Commissioning for allocative value
A key responsibility of commissioners is to optimise allocative efficiency to improve the health and wellbeing of the population. Taking responsibility for the resources allocated to them, determined by a national formula over which they have no control, they have to decide how and where to allocate those resources optimally. The aim of resource allocation, defined by Vilfredo Pareto1 was to reach the point of optimality, namely the point at which no more value can be derived from the resources from shifting a single pound from one budget to another. No commissioning organisation has yet reached this point, local or national.
Commissioning organisations will need to address this challenge and stop allocating resources based on historical patterns of provision, often bound by organisational lines. This is evidenced by examples of the types of headings used by two CCGs when planning and making decisions about investments to health (Table 1).
The Right Care approach challenges commissioning organisations to think about the population served with a focus on the programme budget and the population cohort. After all, if you don’t know what you spend how can you understand the outcomes and make improvements? The key responsibility of the commissioning organisation, therefore, is to allocate a sufficient level of budget to the programmes and then to sub-programmes of care. This can be a demanding process, especially if the commissioning organisation has not been considering the point of optimality when allocating resources, but once organised it can be a worthwhile and rewarding process for the population served and a good place to start is to review the data in the Commissioning for Value (CfV) pack delivered to each CCG.
When adopting this approach there are, perhaps, two levels of allocations that commissioners need to consider. For example, within the programme budget for respiratory disease what is the right allocation of resources among the systems of care for people with asthma or COPD? (Figure 1).
Within these groups, what is the best way to allocate budget to services and therapies?
This is not a process that can be done in isolation and it is important to remember that no one professional group has it the necessary information or knowledge to plan an optimal service, but that all should stil contribute to the commissioning process. However, it is the role of commissioning organisations to manage the commissioning process, pulling all that information together, to use it on behalf of their population to deliver optimal care. Commissioners need to set the context in which the clinicians and patients will accept responsibility for what the Academy of Medical Royal Colleges term “resource stewardship".2 Commissioners must take the lead to encourage clinicians and patient groups to take shared responsibility for the allocation of resources within a programme budget, and then decide how to take that to the next level all within a system of care.
The Right Care approach promotes this method to encourage commissioning organisations to aim for optimal care and to look within each system to decide if the balance is right between prevention, screening, diagnosis, intervention and long-term care. There are tools available to assist commissioning organisations with this complex task, for example the STAR tool3, (short for socio-technical allocation of resources). The approach combines value for money analysis with stakeholder engagement, enabling those planning services to determine how resources can be most effectively invested, with the engagement of stakeholders meaning the decisions made are understood by those most affected.
Commissioning for technical value
Clinical commissioning is challenging but if done well it is rewarding. It is essential that commissioning organisations work across the health care system to maintain a good understanding of what is being delivered and to which patient group. They should not rely on management processes to define technical value for efficiency leaving that to the providers underpinned by written specification and incentives in the contract. Improving quality, safety and cost is core business after all. Right Care maintains this population perspective and offers several different aspects of a population perspective that may influence the definition of value.
The first is to ensure equity. Figure 2 shows a modified graph in the NHS Atlas of Variation in Healthcare (2010).4 The atlas looked at the variation in hip and knee replacement across the NHS and demonstrated a widespread variation in the average EQ-5D PROM score to suggest that populations are receiving these interventions much earlier in the course of disease. Work by Judge et al5 showed that this is not a random effect and that “people in affluent areas get most provision relative to need” – the so called inverse care law.
The role of commissioning organisations here is not to get drawn in to wasteful micro-management of contracts, but to build up a shared relationship with the provider organisation and in particular the orthopaedic department by practicing population orthopaedics.
Secondly, we need to encourage the debate about whether some services are now being delivered at a rate that could be classified as overuse, highlighting the issues raised in the British Medical Journal’s campaign called Too much medicine, illustrated in Figure 3 by Avedis Donabedian.6
Adopting this helpful diagram (Figure 3) should stimulate a discussion with the local population to review which services have yet to reach the point of optimality and also to ask if there are services that have passed the point of optimality. Again, this is a leadership role for commissioning organisations who need to bring together clinicians and patients because it may be unclear to someone working in one particular sector that the rate at which they are providing a service far exceeds that in other similar populations, with the possibility of transferring resources to other higher value activities for the same group of patients.
Commissioning for personalised value
Personalised value is determined by the degree at which the outcome relates to the particular problem that the individual brought to the health service. The role of the clinical commissioners is to be positive about making the space where shared decision making becomes the norm for that population. For example, if an individual presents with knee pain there is no point moving too quickly along a pathway to suggest that a replacement may be necessary without the individual having, at least an equal part in the decision, as there are many factors to consider. The objective measurement of outcome needs to be complemented by the subjective. Commissioners should require clinical services not only to use conventional measures of outcome but to ensure data is collected from the patient. They should answer to the question:
- Since you came to your health service, is the problem that is bothering you:
– Better?
– No better?
– Worse?
Right Care has long advocated and continues to promote the use of shared decision making (SDM) as a way of empowering patients to become part of the solution. There is good Cochrane Library evidence that the use of SDM techniques drive up value for patients. Right Care developed and published 35 patient decision aids7 as part of a wider SDM programme; this work is now being extended through NHS England.
Commissioning for value: the value agenda
This article has shared some of the opportunities for clinical commissioners to move away from an era of planning and investment based on traditional and historical activity and move swiftly toward the value era.
The agenda is to focus on improving the value of healthcare to the whole population as well as the individual patient. Also achieve optimal care through a focus on programme budgets, population planning, and systems of care, as highlighted in the NHS Five Year Forward View. We have often summarised the Right Care philosophy in Figure 4.
We profoundly believe that this approach, based on value, is the most sustainable and ethical way to address the efficiency and productivity gap, compounded by the growing demand for care.
Sir Muir Gray and Philip DaSilva, co-founders NHS Right Care.
References
1. Wikipedia. Pareto efficiency. http://en.wikipedia.org/wiki/Pareto_efficiency (accessed 10 June 2015).
2. Maughan D, Ansell J. Protecting resources, promoting value: a doctor’s guide to cutting waste in clinical care. 2014: 6, 8. Academy of Medical Royal Colleges. http://www.aomrc.org.uk/dmdocuments/Promoting%20value%20FINAL.pdf (accessed 10 June 2015).
3. Right Care. Star: Socio-Technical Allocation of Resources. http://www.rightcare.nhs.uk/index.php/resourcecentre/right-care-for-populations/star-socio-technical-allocation-of-resources/. (accessed 10 June 2015).
4. Gray M, DaSilva P. NHS Atlas of Variation in Healthcare. 2010. 66 http://www.rightcare.nhs.uk/atlas/qipp_nhsAtlas-LOW_261110c.pdf (accessed 10 June 2015).
5. Judge A, Welton NJ, Sandhu J, Ben-Shlomo Y. 2010 Equity in access to total joint replacement of the hip and knee in England: cross sectional study. BMJ 2010:341:c4092. doi: 10.1136/bmj.c4092.
6. Avedis Donabedian.The Definition of Quality and Approaches to Its Assessment. Health Administration Press, 1980, p.12.
7. Shared Decision Making. http://sdm.rightcare.nhs.uk/ (accessed 10 June 2015).
