In PCTs, public health work can be divided into health services we provide (e.g. health promotion and health improvement like healthy eating at schools, smoking cessation, community services for older people etc) and health services we commission (e.g. GP services, maternity services, care pathways for obesity etc). Most commissioning revolves around block contracts and 'payment by results' contracts between PCTs and providers such as acute trusts (i.e. hospitals), ambulance trusts, mental health trusts and the independent sector. There are also contracts with the voluntary or third sector and with primary care. Other types of commissioning include practice based commissioning and specialised commissioning. Under practice based commissioning, GP practices are given the freedom, support and incentives to improve care and services for their patients within a governance framework. The money they have for commissioning is theoretical and they work with special practice based commissioning teams at PCTs. Public health have been involved in the initial benchmarking of needs of the consortia's populations and work with the consortia (or alliances) to ensure that they are matching the needs of the population with appropriate referrals, decommissioning where necessary. Specialist commissioning is mostly done on national or regional levels (often in a host PCT on behalf of a group of PCTs). NHS commissioning is increasingly focused on developing care standards and the quality assurance of provider services
1. Assessment and Planning
2. Contracting and Procurement
3. Performance Management, Settlement and Review
4. Patient and Public Engagement
Public health can help commissioning with planning (needs assessment, review of evidence, deciding priorities), designing and procuring services of a high quality standard and finally, by helping to manage performance, monitor quality and evaluate service provision.
To commission services, you will need to know:
1. Needs of the population
2. What services are available?
3. What changes are needed?
4. Agree how and where to purchase.
5. Monitor performance of providers against agreed contracts.
Health authorities setting up contracts with hospitals will need to decide between different services and which should have priority. In Health of Nation, Department of Health set up the principles for the development of services (1) effectiveness (2) efficiency and(3) health improvement. You will need to decide between values of high quality or cheapness or compromise. To commission any service, you need the element of a perfect market (i.e. many buyers and sellers, free entry and exit, homogeneous product, perfect information and no externality (i.e. I pay and someone else benefits). For specialist commissioning (this is for rare conditions e.g. for haemophilia or chronic kidney disease, specialised cancer services, motor neurone disease etc), you will also need to consider insurance, high costs, whether or not population demand is predictable and whether an individual's probability of demand is independent.
Commissioning services is based upon Bradshaw's 'Need, Supply and Demand' model. Balancing demands and need requires a set of values upon which health services provision can be based.
These values are:
(1)Equity (expensive treatments are limited in favour of the cheaper)
(2)Greatest potential for improving health (purchasing is based on the greatest number of lives saved and disabilities avoided e.g. smoking prevention by the GPs tends to be the most effective here)
(3)Accessibility (this tends to favour primary care; acutely ill people have less priority)
(4)Best possible service for everyone (these services are likely to run out of money because of spending on services of marginal value)
There are a number of factors that influence the quantity of services needed. These are disease incidence and prevalence including 'new' diseases (Incidences and prevalence measures do not automatically provide a measure of 'need' for health care); Medical technology and other pressures such as public opinion, politicians, press, voluntary groups and community health councils.
This involves looking at a service(s) and deciding how you can best deliver this service (i.e. maintain and improve quality) within a budget. It very often leads to more efficient and effective services. Procedures used include:
1. Decommission unneccessary or ineffective interventions
2. Use methodologies for taking costs out of the system
3. Redesign services
4. Move services, where appropriate, from acute trust to community
5. Collaborative procurement between partners
This has been in operation since 2003. Prior to that, block contracts were awarded to acute trusts (and mental health trusts) to provide services with prices based on historic local costs and negotiating skills. It was difficult for commissioners to see what outputs actually cost and to identify and deal with inefficiency by the provider. With payment by results (or really it is payment by activity), there is a set tariff per activity and income is generated by the provider by simply multiplying the price by activity. Pricing is determined through classification (i.e. a system of codes is used to record clincial diagnosis and procedures in a standardised way), currency (i.e. codes are grouped together on the basis of clincial and financial similiarity to provide standardised units for payment knowns as health resource groups) and costing (i.e. there is a standard price allocated to the health resource groups on the basis of the reported cost of provision across the acute sector). This tarriff is a mandatory national price that is paid by PCTs to all providers regardless of location. There is however top-ups which are paid by centre to reflect unavoidable differences in costs of providing services in different parts. PCTs also pay for each bed day over the defined period for each health resourse group if a patient's stay in hospital exceeds it. Payment by results has helped to strengthen commissioning. PCTs can monitor provider activity and performance and can now focus on demand management. However, not all services are included in payment by results, for instance, community services.
This was first raised in the NHS Operating Framework (2006/7) but has recently gained momentum in the recession. Under the NHS Operating Framework, demand management was said to consist of three components. Firstly, practice based commissioning was said to be an effective demand management measure as it ensured that all GP practices have the incentive to control referrals and other use of services. This freed up resources which could be re-invested to improve services. Secondly, PCTs could have provisions in contracts with hospitals, for instance, having expected clearance times for existing waiting lists, to help demand management and finally, there should be monitoring arrangements. PCTs and acute trusts should have joint responsibility for agreeing measures to deal with significant variance from plan, for example, freeing up resources for redeployment when activity is reflecting changes in patient choice or if there is a genuine unexpected increase in demand for a service.
Since then, demand management has focused on hospitals who are operating high levels of activity and comprises of redesigning pathways and referral management. To have appropriate effective efficient health services for patients, you need: (1) effective management of elective referrals; (2) alternative primary care provision using GPs with special interests; (3) A&E diversion schemes back to primary care and (4) effective contractual arrangements.
Public health have been involved in some places in reviewing the referral process and pathways (including appropriateness of GP referrals and making consultant-to-consultant referall pathway more effective), reviewing treatment times, helping to develop primary care provision points instead of A&E where possible and helping to develop effective case management by communicating and installing best practice guidance.
Each PCT should have a strategy that sets out to achieve:
1. Health gains.
2. Reduced inequalities.
3. Improved quality of care.
This should be underpinned by a robust long-term financial plan and there should be a sustainable financial position.
What does WCC do?
The idea is to give PCTs the skills to be at the forefront of delivery improvements to all parts of their local population using principles of QIPP (Quality, Innovation, Productivity and Prevention).
Aims
1. Achieve better outcomes
2. Have world class performance
3. Reduce health inequalities
WCC holds PCTs to account for performance improvements in commissioning capabilties and outcome improvements. It also rewards success and it provides a common basis (PCTs' results are published by Department of Health at end of year 2.
There are 2 given WCC outcomes:
1. Reduce health inequalities
2. Increase life expectancy
PCTs can have up to 10 others - e.g. they can include reducing teenage conception rates or C.Difficle rates, reduction of obesity amongst school age children, increase % of breastfeeding at 6 weeks.
1. Locally lead the NHS
2. Work with community partners
3. Engage with public and patients
4. Collaborate with clinicians
5. Manage knowledge and assess needs
6. Prioritise investment of all spend
7. Stimulate the market
8. Promote improvement adn innovation
9. Secure procurement skills
10. Manage the local health system
11. Efficiency and effectiveness of spend
1. Provide robust health needs assessments (and be proactive in getting them to influence service redesign)
2. Provide evidence/best practice
3. Be involved in budget managing - i.e. priorisation ('value for money')
4. In many PCTs, the Director of Public Health also has responsibility for attaining one or more of the WCC competencies.
A useful source of information on commissioning can be found at www.ic.nhs.uk/commissioning.