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With reforms underway, is the NHS turning into a marketplace? CUTTING RED TAPE How to establish a clinically-led organisation without the bureaucracy

ON WITH THE SHOW Commissioning Show 2012: a guide

Editor’s letter



elcome to the second edition of Commissioning Success magazine. Now that we’ve got the ball rolling here at CS Towers and the Health and Social Care Bill has become an act, we want to hear from you. How’s it going? Got any success stories? Please get in touch on and share your experience, because once all the fanfare dies down, all that will be left are the CCGs and eventually the lion’s share of the NHS budget. Do you think you can cut it? It seems from the commissioners I’ve met you certainly can. On page 18 I interview Wigan Borough CCG, which is making waves with COPD through a ‘Breathlessness’ campaign. They’ve taken an interesting approach to commissioning by keeping localised minigroups within the larger commissioning organisation to ensure ‘local’ stays on the table. On page 22 I speak to the very forward-thinking Durham Dales CCG, which is nominated for a BMJ Award for their commissioning work. They really are covering lots of bases – from diabetes to IBS and even putting beds in GP practices. The idea of keeping local at the heart of commissioning seems to be important as CCGs prepare to take over responsibility for commissioning care from PCT clusters come April. In his speech at the annual BMA’s GP conference, Dr Laurence Buckman, chairman of the BMA’s GPs committee warned that many GPs are feeling left out of the commissioning game. Of course, this is understandable as commissioning has truly become a day job for those involved, however, the CCGs that I’ve seen doing a great job of things have involved everyone – both directly and indirectly – whether that be through monthly CCG-wide meetings or groups that feed information to the board. It’s important that every patient voice is heard and to do that, a lot of fingers need to be in a lot of pies.


News and updates The latest news, comment and views on clinical commissioning


Be prepared Dr David Paynton, national clinical lead at the RCGP Centre for Commissioning readies CCGs for the year ahead


Commissioning Show 2012 A commissioner’s guide to the annual CCG event


We’re all off to market Now that GP-led commissioning is well and truly here, Roger Hymas looks at where the journey will take us COMMISSIONING IN ACTION


Wigan Borough CCG Dr Tim Dalton, clinical chair, and COO Trish Anderson, take a big picture approach to commissioning pathways


Durham Dales CCG The dream team at Durham Dales commissioning locality is making waves with its pathfinder work COMMUNITY CARE


Reduce and deliver Paul Robinson offers advice on reducing hospital admissions


Forget me not Working together to tackle dementia INFORMATION AND TECHNOLOGY


Top tips Five ways to improve data exchange in your commissioning group


Telehealth How CCGs can take advantage of telehealth for better outcomes MANAGING COMMISSIONING













Understanding procurement Ways that CCGs can understand and procure even better


Just say no Cutting back on red-tape so commissioners are left to commission

Commissioning Success is published by Intelligent Media Solutions Suite 223, Business Design Centre 52 Upper Street, London, N1 0QH tel 020 7288 6833 fax 020 7288 6834 email web web Printed in the UK by Buxton Press


NEWS WAVE 1 CCGS ANNOUNCED The NHS Commissioning Board Authority has confirmed the 35 aspiring clinical commissioning groups (CCGs) in the first wave of authorisation. These are: • Bassetlaw • Blackpool • Bedfordshire • Calderdale • Cumbria • Dudley • East & North Herts • East Leicestershire & Rutland • East Riding • Gloucestershire • Great Yarmouth & Waveney • Islington

• Kernow (Cornwall) • Kingston • Leicester City • Liverpool • Newbury & District • North & West Reading • North East Lincolnshire • North Staffordshire • Oldham • Oxfordshire • Portsmouth • Rotherham

• Sandwell • West Birmingham • Shropshire • Somerset • South Reading • Stoke on Trent • Wakefield • Wandsworth • Warrington • West Cheshire • West Leicestershire • Wokingham

Applications for authorisation will take place in four waves from July 2012 to January 2013. Meanwhile, in the second stage in the business review process for commissioning support services (CSSs), three services failed to make the cut. The objective of checkpoint two is to assess whether emerging CSSs are on are track to developing a full business plan by August 2012 when they will undertake the final checkpoint, prior to a decision on hosting arrangements by the board authority. Twenty-six regional NHS commissioning support services and the nationwide NHS Communications and Engagement Service submitted business plans for checkpoint two. Of these, 14 had “medium to low issues”; nine “need more rapid management”; and three failed to pass.

HEALTH ACT TO IMPACT DATA The Health and Social Care Act 2012 will have “severe implications” for collecting and monitoring data about the health needs of the population in England, warn experts In a paper published on, Professor Allyson Pollock, Professor Alison Macfarlane and Sylvia Godden argue that the new legislation will make it “extremely difficult” to monitor health inequalities and access to care locally or nationally. The administrative structure of the NHS in England is currently based on resident populations of defined geographical areas. Under the new legislation, most health services

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will transfer to non-geographically based CCGs that will be able to recruit patients living anywhere in England. This, warn the authors, is likely to lead to erosion of data quality, accuracy, and completeness. They conclude: “The NHS is founded on the principle of comprehensive coverage. Equitable public health activity requires reliable information. The abolition of area-based structures and the transfer of most responsibilities to nongeographically based CCGs, as well as some responsibilities to local authorities, undermines the availability of information and routine data required to monitor service.”

More training needed for managers According to the latest research from the Institute of Healthcare Management (IHM) over three quarters (78%) of managers surveyed in the healthcare sector believe that patient care is at risk due to a lack of proper staff training and development. Some 87% of those surveyed believe this training gap has resulted in low team morale while a further 87% cite a lack of confidence in staff as a direct consequence, resulting in slipping standards and ultimately, putting patients at risk. The survey comes in the wake of the King’s Fund’s report into leadership for engagement in the NHS.


Newark takes a breath of fresh air Chronic Obstructive Pulmonary Disease (COPD) lies at the centre of the QIPP agenda for Newark and Sherwood Clinical Commissioning Group. As a result, they have embarked on an innovative approach to improve care for patients with this condition by joining forces, not only with the local acute trust, community providers and patients but also with the pharmaceutical industry to create PANNASH – the Pulmonary Advancement Network for Newark and Sherwood Health, to help people with COPD better manage their condition.



Sunderland Men’s Health Network reaches out to men in the local area Men in Sunderland were invited to stop by a local network event in April, aimed at involving local people in tackling men’s health issues. Sunderland has some of the worst areas of deprivation in the UK and although overall life expectancy for people in Sunderland is increasing, the gap between Sunderland and the rest of England is not closing, especially for men. In the last two years life expectancy for men has widened slightly. The latest information suggests that average life expectancy for men is 75 years compared to 77 years for England. Last year the public health team at Sunderland Teaching Primary Care Trust (PCT) set up a Men’s Health Steering Group, made up of a range of organisations across the public, private, community and voluntary sectors that focus on men’s health. As part of this the Men’s Health Network was launched with bi-monthly meetings to bring men from across Sunderland together to discuss men’s health to ensure they themselves can contribute to the evolving health improvement initiatives.

Yusuf Meah, promoting health practitioner for Sunderland Teaching PCT said: “We are encouraging men to stop by the Men’s Health Network event which is raising awareness of men’s health issues and encouraging men to get involved. The network gives men the opportunity to become aware of the current work on men’s health in Sunderland which aims to narrow the gap of male life expectancy.” There are a number of health issues that contribute to high male mortality in the North East and specifically Sunderland, including lung, prostate, testicular, and bowel cancer.

CLINICAL CORNER NAO CONDEMNS DIABETES CARE The National Audit Office has issued a report finding that, despite some improvements since 2006-07, there is poor performance against expected levels of care, low achievement of treatment standards and high numbers of avoidable deaths, and concludes that diabetes services in England are not delivering value for money. In 2009-10, there were an estimated 3.1 million adults with diabetes in England. The number of people with the condition is expected to increase by 23% to 3.8m by 2020.


NHS South of Tyne and Wear uses technology to monitor LTCs Patients with long-term conditions in South Tyneside are able to monitor their health at home reducing hospital admissions and visits to their GP thanks to new a new telehealth initiative in the area. The telehealth team at NHS South of

Tyne and Wear won the partnership award in Sunderland City Council’s Star Awards 2012 in recognition of creating a successful partnership across South of Tyne and Wear, to develop and promote telehealth and assistive technologies. Paul Marriott, project manager for telehealth at NHS South of Tyne and Wear, said: “Telehealth aims to improve the health and wellbeing of those people with a longterm condition by enabling them to manage their condition more effectively. It also supports earlier discharge from hospital and supports people in their own home rather than admitting them to residential care, and increases patient and carer independence.”

DIARY 20-22 June NHS Confederation Annual Conference and Exhibition Manchester Central Convention Complex


We are always looking for local commissioning news. If you have a story to share, email

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Be prepared With clinically-led commissioning upon us, DR DAVID PAYNTON, national clinical lead at the RCGP Centre for Commissioning readies you for the year ahead

“This year should

be regarded as the shadow year in which CCGs will need to gain the respect of their practices, go through the authorisation process and keep costs under control”


linical commissioning sets new challenges and opportunities for the NHS and primary care, being fundamentally different from primary care trust commissioning in that clinical commissioning groups are: • membership organisations, with the membership coming from the constituent practices as well as being a statutory bodies • commissioning for outcomes as opposed to PCT contracting for activity • accountable to local authorities via the health and wellbeing boards as well as the National Commissioning Board • and must find ways of meaningfully involving their local population. Some things remain, however, including the need to maintain financial balance at a time of an increasing aging population and very limited financial growth. This year – 2012/13 – should be regarded as the shadow year in which CCGs will need to gain the respect of their practices, go through the authorisation process and keep costs under control. Developing the leaders of the new organisation is only part of the story in that no matter how competent the organisation, it is essential to develop the right commitment from constituent practices. RCGP CENTRE FOR COMMISSIONING The RCGP Centre for Commissioning was set up in 2010 to equip its members with the skills, competencies and expertise required to deliver effective clinical commissioning. Clinically-led commissioning is a continual process of: • analysing the needs of a community • designing pathways of care • specifying and procuring services • monitoring services to ensure they improve agreed health and social outcomes, within the resources available. Good commissioning places patients, as individuals, at the centre of the process requiring a very different approach, but building up from a practice base.

THE CLINICAL COMMISSIONING CYCLE – KEY PRINCIPLES AND VALUES Clinical commissioning groups, local authorities and others need to work together to plan and deliver better integration of local services. While competition can be a means to an end, the language of the market should not be allowed to replace our first duty to improve the health and wellbeing for our patient and local population within the resource available. Effective commissioning should be based on the following core principles: • collaboration – working with the full range of partners to develop effective, sustainable and integrated healthcare systems • community focused – engaging local people and communities throughout the commissioning cycle and prioritising the needs of patients and the public • comprehensive – meeting the healthcare needs of the whole population, including the disadvantaged and the vulnerable to improve health outcomes • clinically-led – putting clinicians at the heart of designing and delivering innovative, evidence- based and high quality healthcare services. This is the first real test for CCGs, to establish the right relationships, values, clinical strategies and processes if they are to really transform the local system. This article is adapted from ‘Principles of Commissioning Summary’, one in a series of resources produced by the RCGP Centre for Commissioning ( commissioning.aspx)

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Commissioning Show guide 27-28 June 2012

Olympia, London The second annual Commissioning Show is set to be a good one. We bring you everything commissioners need to know to make the most of the show, including the best seminars to attend, a list of speakers and how to get there

R WHAT’S NEW FOR 2012? • Best practice working with local authorities • Technology hot topics • Table your own round table • Book one-to-one sessions with experts • Hands-on facilitated workshop sessions.

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egistration is now open for one of the UK’s largest commissioning events. With the changes well underway that will bring about a primary care-led health service, you can join over 3,000 GPs, healthcare leaders and local authority stakeholders leading the way in delivering better patient service. But the Commissioning Show is about much more than listening to the key issues debated by some of healthcare’s most influential figures. It’s really about the commissioners themselves and the experience they can offer each other, all the successes and cautionary tales from those on the road to authorisation – however far along. Commissioning gives attendees the platform to put burning questions to policy makers, experts, local authorities and healthcare peers. From round-table sessions to panel debates, you will have the opportunity to share ideas, not only with top policy makers, but with fellow practitioners who can offer practical ideas and inspiring case studies. It is the only event where all the individuals shaping the future of healthcare will be in the same place, from GPs, to healthcare managers to local authority to public health and social care. It is the place to get face-to-face with the future of healthcare.


COUNTING DOWN TO IMPLEMENTATION Moving towards implementation will be the main thought on the minds of clinical commissioning group (CCG) leaders when they come to the 2012 Commissioning Show in June. Their main concerns will be around the practicalities of getting themselves ready to start commissioning, says Dr Charles Alessi, chair of the National Association of Primary Care and a member of the Clinical Commissioning Coalition, run jointly with the NHS Alliance. One of the challenges will be for CCGs to understand what their responsibilities are around the use of any qualified provider (AQP). The Coalition recently forced the Government into a U-turn on the use of AQP with commissioners now entitled to decide if and when they open up services to competition. “Now we can use AQP in a way in which everybody will be comfortable with. CCGs may use it or not as they wish,” Dr Alessi adds. Dr Alessi, who is speaking at the Commissioning Show, says that delegates will be wanting to find out more about what commissioning means, understanding how to commission, how to use health and wellbeing boards and what authorisation means. “At the moment CCG leaders are not feeling confident. We are still at the stage where we are going through a messy transition. It’s inevitable.” HEALTHCARE LEADERS TO DEBATE CHALLENGES FACING CCGS Setting the quality and patient safety agenda, while managing finances, is set to be a key theme of a leaders symposia, sponsored by Capita, which closes the first day of the conference. Four national healthcare leaders will give their opinion on the immediate implementation challenges facing CCGs and how these problems can be overcome. The debate promises to be stimulating with

the speakers including Dr Alessi; Peter Swinyard, chair of the Family Doctor Association; Dr Michael Dixon, chair of the NHS Alliance and Professor Steve Field, chair of the NHS Future Forum. The session will be chaired by Beverley Bryant, MD of Capita Health. While current attention is inevitably focused on the need to achieve authorisation, the underlying challenge facing CCGs remains the need to sustain patient safety and quality whilst realising £20bn of efficiency improvements. In addition, many CCGs across the country will inherit health economies that are either already financially challenged or unsustainable over the long term in their current configurations. Andrew Lawrence, Capita’s MD for commissioning, commented: “Post-authorisation is when the task of implementing innovative forms of commissioning begins in earnest. The need to embrace new ways of working will be vitally important to bring long term stability to many health economies. “It needs to start with applying commissioning techniques which are grounded on practice populations and help better coordination across health and care services. CCGs will also demand information tools increasingly driven by real-time data, enabling clinicians to anticipate patients’ needs for healthcare services before, rather than after, they are incurred. “Better information coupled with the increasing use of outcome-based contract levers and incentives, means CCGs have a real opportunity to influence priorities and drive improved provider performance. “This is when the work of authorised CCGs really begins.” For more information, or to view the full programme of events, visit

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LIST OF SPEAKERS Plenaries, keynote workshop speakers and chairs are set to include: • Andrew Lansley, secretary of state for health • Mike Ramsden, chief executive, NAPC • Dr Charles Alessi, chairman of the NAPC and senior GP partner (top left) • Dr James Kingsland OBE, GP and NAPC president • David Colin-Thome OBE, chair Primary Care Commissioning (PCC) • Dame Barbara Hakin, national MD of commissioning development (bottom left) • Cynthia Bower, chief executive of the Care Quality Commission • Dr Johnny Marshall, executive member, NAPC • Dr Michael Dixon OBE, chair NHS Alliance • Roger Hymas, chief executive of Healthcare Commissioning Services • Dr Gillian Leng, deputy chief executive, NICE • Mike Farrar, chief executive, NHS Confederation • Julian Patterson, director of marketing and communications, Primary Care Commissioning (PCC)

GETTING THERE London Olympia is an easily accessible venue from all forms of transport, including Heathrow and Gatwick airport, all major railway stations and motorway routes, as well as by underground and British Rail. Olympia has its own dedicated overground railway station: Olympia-Kensington (Olympia). Turn left out of the exit of the station onto Olympia Way and follow signs for Olympia Two and Olympia Conference Centre. Direct trains come regularly from Clapham Junction, Watford Junction, Milton Keynes and stations in between. Further direct services connects the overground with Shepherds Bush, Willesden Junction, West Hampstead, Finchley Road, Camden Road, Caledonian Road, Dalston, Hackney Central, Stratford and stations in between. Olympia is served by the following bus routes: Hammersmith Road: 9, 10, 27, 28; Holland Road: 49; and North End Road: 391. DRIVING DIRECTIONS TO OLYMPIA From M1/A1/M11/A10 take the A406 westbound to A4. Continue on A4 over Hammersmith Flyover, turn left onto the B317 (North End Road) and follow signs. From M4/A4 follow directions as above. From A3/M3 follow signs for central London, take Wandsworth or Putney Bridges. From Wandsworth Bridge, turn left onto New Kings Road, turn right onto Fulham High Street, which becomes Fulham Palace Road. At Hammersmith roundabout turn right onto Hammersmith Road and follow signs. From Putney Bridge, turn left onto Fulham Palace Road and follow directions as above. From M2/M20/A2 follow signs to central London, take Blackfriars, London, Waterloo, Vauxhall, Southwark, Chelsea or Battersea Bridges, turn left along Embankment and follow signs. From A12/A13 follow signs for central London towards Tower or London Bridge. Do not cross bridge, instead continue along Embankment and follow signs. Earls Court and Olympia are easily accessible from London’s four airports - Heathrow, Gatwick Stansted and City Airport - via underground and mainline rail services. From Heathrow airport Take the Piccadilly line to Earls Court. For Olympia, change onto the District Line to Kensington Olympia. Alternatively take the Heathrow Express to Paddington and change onto the District Line to Earls Court. The address is Hammersmith Road, London W14 8UX

HOW TO BOOK Free tickets are available for readers of Commissioning Success magazine. To book yours, quote special code “CSFree” at check out on

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The future of the NHS? We’re all off to market Now that GP-led commissioning is well and truly here, ROGER HYMAS looks at where the journey will take us


AUTHOR BIO Roger Hymas is a former MD of Bupa and director of commissioning for Hampshire PCT. He is also the founder of the Commissioning Community website,

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o, the era of GP-led commissioning is well and truly under way. But exactly where will it take us? I was brought up in the strategic planning school of looking at where markets, industries, and endeavours will end up at some fixed point in the future and then trying to work my way back to the present. So, if we choose where the NHS will be five years from now – say 2017 – how different will it look from where we are right now? Unpopular as it will be for many, there’s absolutely no doubt that a sophisticated healthcare marketplace will come to exist. This is the inevitable consequence of the provisions of the health bill, now of course an act. This provided even more impetus to the trajectory of creating the marketplace that the NHS had been building for some time. The bigger canvas, the separation of providers and purchasers, got started back in the Blair/Milner era with the creation of PCTs, although the first initiative, GP fundholding, was launched as far back as the early 1990s. But it never really got going, nor during their brief existence, did PCTs get themselves into a position to have any real market influence. Now GPs are being given the purchaser role and

will commission healthcare for their populations. I think GPs, as they learn their role and adapt to the prevailing circumstances, will just make it happen. It’s their turn to line up against the large FTs and put their countervailing business strategies in place. I think GPs will relish the task: it’s just possible that they will find both the expertise and assertiveness that was missing during the PCT regime. Three years ago I had a ringside seat and a glimpse of the future in a tussle between a PCT (its next door neighbour had gone bust and seen its senior management get fired en masse) and the hospital – a recent foundation trust – that was deemed to be overtrading. The PCT wouldn’t sign its contract until it was certain about the hospital’s activity level. The PCT put the hospital onto a block contract – passing 1/12 of the prior year’s budget to the hospital on a monthly basis. The hospital went bust, most of the board got fired and the secretary of state bailed out the trust, with a long-term loan with significant strings attached. It’s possible that we’ll start to see this sequence of events replaying itself all over the country in the next few years, certainly within our chosen time frame of 2017. So, I definitely expect to see the NHS in England to evolve to be a complex, sophisticated market, although it will never be a perfect one. There will be


built-in distortions, usually politically-driven, usually justified as a need to protect the public interest. The Government’s inability to separate the secretary of state from the NHS during the passing of the act means that the market for a long time into the future will be vulnerable to political manipulation. Markets always need a cast of engaged players so how will they line up and what will be the motivations which drive their behaviour? COMMISSIONERS NOW CCGS AND GPS We start with 212 CCGs, which means an average of around 200,000 patients each, too few for real economies of scale in back-office administration or to build viable risk pool. To date, we’ve had little guidance from the DH about how it plans for risk to be managed, but for the players involved, it will in the future influence much of their own decision-making, particularly as they learn the terms of market engagement. It’s likely that the really large risks will end up in a regional pool under the control of a specialised commissioning group. Around £30bn has been set aside to manage specialised risks and pay for complex cases. There are huge opportunities for savings in this sector and I see it as a smart move by the NHS Commissioning Board to assume responsibility for the SCG risk pools. This arrangement will provide the scope for a range of procedures to move in and out of the scope of specialised commissioning and provide headroom to help balance CCG, and therefore NHS, budgets. Having as many as 250 CCGs may have its downsides, but it will promote locality commissioning, which I see as a real benefit. The CCG meetings I’ve been to recently are already beginning to understand the value of community commissioning. Most GPs like working at this level of scale. Certainly, a sense of collectivism, federation even, is starting to build, which I think will be positive for local healthcare. But, ‘localism’ in healthcare has a downside and that is in treatment practice variation. There is a phenomenon in health economics called ‘The surgical signature’. This occurs because health systems have normally grown around a dominant neighbourhood hospital and local health care is hugely influenced by the customs and

practice of that hospital. Also, local healthcare practitioners are very protective of their DGH – even if its quality in some aspects of delivery is sometimes dubious – adopting a kind of reverse nimbyism. The practices, processes, motivations and ambitions of the local DGH will have a huge influence over variation and, therefore, quality of outcomes. That’s why NHS Choices is a significant part of the DH policy agenda. Expect the push to quality measurement to increase competition and widen hospital catchment areas as patients travel further for a higher quality solution. Hospitals will start to make access easier, particularly for conditions, procedures, where they want to build market share and attract high value patients. PROVIDERS This covers the range from large foundation trusts all the way down to GP practices that do the odd procedure or diagnostic test. NHS budgets are finite and with the growing pressure on government finances, funding is going to get much, much tighter. Arguably, the healthcare market is currently over-supplied. Even though that is the case, there’s been a huge resistance to closing or downsizing hospitals. Providers seeking to build market share will create the new battleground: to keep on growing – and businesses have to – DGHs will be seeking to take business from their neighbours, starting where their catchment areas overlap. But the biggest feature – and this is the game changer – is that it’s GPs, historically the gatekeepers, will become supply chain managers. Top of their minds will be the need to regulate demand and control supply to ensure that their CCG does not go bust. Local tariffs will begin to push down national rates. Those providers with the highest cost bases (usually those carrying the biggest overhead) will come under the most financial pressure. The signs are there already. Most GPs, of course, already double-up as providers. They always have done. But in the future many more will see the financial benefit of expanding their providing capability. All GPs will assume a commissioning role and many will recognise that the requirement of balanced budgets will require them to move their patients to the lowest cost solutions, often provided not by hospitals, but by their GP colleagues.

THE NHS COMMISSIONING BOARD While its principal role will be to regulate primary care, as far as CCGs are concerned, the NCB will often seem to them to be the government enforcer. Most of the NCB staff comes with a cultural orientation towards the provider interest. There is no strong tradition of commissioning experience among DH/ NHS officials and they will struggle to adopt a true commissioning mind-set. None that I know of has had first-hand experience as a commissioner in industrial-scale healthcare: for example, nobody senior has worked in the US HMO industry. There are plenty of statisticians and economists in the DH, but no actuaries, the real controllers of commissioning finances. This could mean, rather bizarrely, we could see a disconnect between what the Government wants to see delivered and what gets done. Creative destruction doesn’t sit very well with healthcare systems, although perversely it is an essential driver of medical technology and pharmacology progress. Local health economies are notoriously conservative and resist change. They don’t do the radical as Andrew Lansley will now attest. When it’s attempted, every big bang change is opposed by equal and opposite resistance. COMMISSIONING SUPPORT SERVICES These will have a huge role to play as the CCG back office. CCGs are well advised to spend the maximum attention over the next twelve months to researching and contracting their support arrangements. A poor CSS will be a critical factor in frustrating CCGs’ own ability to deliver commissioning effectively, in the worst case leading to its downfall. CCGs will be free to choose wherever they get the service in the market: they should spend as much time as they need making sure that they get the right help. They should beware of snake oil doctors – this is a tricky environment for inexperienced purchasers. Certainly, CCGs would be well advised to avoid long-term contracts in the first instance. LOCAL AUTHORITIES These will have a new and expanded role in health care. Expect many of them to be assertive in defending the needs of local populations, particularly in the big conurbations, where they

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will see the importance of plugging the commissioning and public health management gaps when SHAs go away. They and CCGs should create strong working relationships. PATIENTS These can be grouped into a variety of guises – consumers, users, patients, carers, the public. What you can be certain about is the coming patient typologies are going to be different from previous generations, particularly those who benefitted hugely from the invention of the NHS and have been forever grateful for it. But the new force in health care consumerism will be the baby boomers who have a completely different attitude to life – and death. They will be active, assertive, increasingly vociferous, even strident, consumers. We should expect a good measure of patient activism. Consumers will respond to changes in care patterns, given the right incentives. As they do for everything else they buy, they will look for quality and convenience. Many patients, particularly those with mobility issues, will value not making the trek to hospital. Local tests (at the surgery), Skype consultations, home care (yes, it will resurge) are all part of the future. Ask any high street retailer to tell you what happens if you lose customer footfall. Business falls off rapidly. Look at the success of the Internet – Amazon and the like. It’s the triumph of consumer self-interest. Providers will learn how to bundle the best care with the best amenities.

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If I were a major provider, I’d build bigger car parks, but charge nothing for using them. In major cities I’d put a free return taxi trip into the high margin procedures which my service line analysis tell me is where I make good profits. They will restlessly pursue the health care solutions which they think are best for them, increasingly relying on the Internet and will always respond to the best offer. What I don’t think has yet soaked into the consciousness of most people is just how very different the future is going to be. The large providers are reckoning on demand going up continuously; it’s firmly build into their business plans. Certainly, all the signs – demographics, technology, consumer demands – look like they’re pointed that way. For the next twelve months as we transition from PCT-led to CCG-led commissioning, true, it’s not going to look like many of the other years since 2006, when PCTs got going. But a lot of lessons are going to start to get learned very quickly this year. GPs are a wily bunch and will quickly start to work out the angles. This is the way they’ve always managed the NHS: and now they’re in control. What I’m predicting is that subtly, but inevitably, the reality of a market place is going to come into shape. And subtly and slowly is the way that health care markets go about change. It’s the little movements which happen one by one, mostly on the margin. Healthcare is conservative. It changes incrementally, patient

“The Government’s inability

to separate the secretary of state from the NHS during the passing of the act means that the market for a long time into the future will be vulnerable to political manipulation” experience by patient experience, but change it will. The first trend we’ll see is for GPs to refer fewer patients to hospital. There will be local substitutions – a GP provider for a hospital; or a community trust for a hospital; under patient choice, an independent sector provider for an FT. New care pathways will be tried out and slowly become the convention. Indeed, this is the essential pre-requisite to revolution. Patients will only move to new solutions when everyone is confident that they will deliver safely, another given of a conservative market place. Now all what I’ve just described, of course, added together, begin to look like the characteristics of a classic health insurance market. This is where I know, emotionally, I’m going to lose a lot of you. Many NHS stalwarts don’t like the analogy I make between the US system and the future health service in England. But, I’ve observed the evolution of health care markets on both sides of the Atlantic for 20 years. I can tell you that all the factors I’ve listed began to happen in the US as long as 25 years ago. This means that certainly within the next five years we’ll see CCGs begin to behave like HMOs or health insurance plans.


The rest then, and particularly the way the players continuously adapt and modify their roles in a market place, means that everything else falls into place. Excellent business services are required to support CCGs. This is why getting best quality commissioning support is so vital to the success of the future NHS. For a start, the dependence on analytics will strengthen. In a healthcare market, everyone wants to see the evidence. The data covering ‘claims’, provider invoices, will be the centrepiece of the metrics as they are critical to managing costs. The benefit of tracking the money becomes paramount, because this will help CCGs understand financial risk, and how they can avoid it. Expect in time that every patient pathway will have its own P&L account. Measuring outcomes to drive quality will be a big feature, arguably the most important one for driving the next generation of NHS policy. And, of course, GPs are in the best place to both observe, manage and influence outcomes as they navigate and manage patients through the care system. This means that both patient experience and patient satisfaction will become key measures, particularly as selfinterested baby boomers look to secure the best possible experience for their health condition. All this takes us to the inevitable conclusion that commissioning evolves to be a management science. CCGs will expect CSSs to help them search for the best, most cost effective way of achieving the best

outcomes. That’s their principal role. New measures of efficiency will also need to be sought out: outcomes, outputs, will always be more important than inputs. That’s what good commissioning always delivers. Practice data are the new crown jewels. Providers will want them, as well as Big Pharma, actuaries, re-insurers, econometricians, Public Health, even geneticists (the Human Genome plays a key part in future personalised medicine). Analytics will get more sophisticated the nearer you get to the end game, because knowledge is genuinely power. Commissioners will learn to invest more in commissioning practices where they deliver good value. Return on investment – what you get out of your commissioning spend – then becomes a more important consideration than the current arbitrary and paltry allocations of cash for commissioning support. Like insurance companies, CCGs will invest more on back office systems to drive down claims cost. The NHS has to adopt insurance company conventions. But it will do. Start out by checking what ‘loss ratio’ and ‘expense ratio’ mean. What you will find is that if you spend £100 on improving commissioning intelligence and save £500 on the care bill, or £10,000 and save £200,000, you should always spend the money. You have a positive return on the investment. The £100 or £10,000 are the Expense Ratio, the £500 or £200,000 are the Loss Ratio. That’s why the piddly

amounts of money allocated to CSS are a false economy and a complete policy mistake. This comes about because politicians and DH officials, sensitised about bureaucracy and its cost, don’t understand that you have to spend as much money as necessary in rooting out the costs in the system and then finding ways of reducing them. Everyone will soon learn, it’s part of the journey. So, when you add all of this together, all of the players in the new market place will become engaged in what can only be described as a kind of Darwinian mash-up. But what you can be absolutely certain about is that each will be out to protect and promote their self-interest. So, by 2017, what can we expect? A rapidly contracting hospital base. Many specialists, maybe single function providers – close to surgeries, certainly more GP provider businesses. The number of CCGs staying at about 250, but only as locality commissioners. We’ll probably be down to 50 risk bearing organisations. CSSs going from 25 to 15 to 5, most of them private providers, although GPs will work out that it would be best if they controlled them, not surrendering them to the big BPOs. What I’m saying to you is that the NHS landscape is going to be completely different. Because of the changes which will take place, so will be your role. Just you wait and see. Better still, get out there and start deciding your own future. Before somebody else does.

MAY/JUNE 2012 | 15



Is your secondary care provider shopping with your commissioning credit card? The current funding model for malnutrition

References: 1. Stratton RJ et al. Clin Nutr Supplements 2011;6(1):16. 8. Cawood AL et al. Clin Nutr Supplements 2010;5:123. 2. Cawood AL et al. Clin Nutr Supplements 2010;5:123. 3. Stratton RJ et al. Age Res Rev 2005;4(3):422-450. 4. Cawood AL et al. Proceedings of the Nutrition Society 2010; 69 OCE7, E544 5. NICE Cost Saving Guidance. April 2012 benefitsofimplementation/costsavingguidance.jsp

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THE BACKGROUND Malnutrition appears on the radar of commissioners largely as a result of a medicines management drive to reduce expenditure on Oral Nutritional Supplements (ONS). However, there is a lot more to this complex and fascinating subject than meets the eye. Most health economies have a contract with one of three main providers usually associated with ONS and Enteral tube feeding (ETF) and encompass primary and secondary care, directly or indirectly. Historically, these contracts have been driven by procurement teams with an acute trust perspective. Over the years, this has evolved into a model where competitive procurement has driven down the cost to the acute trust (ONS and Tubes) at the expense of PCTs who inadvertently protect secondary care activity through primary care prescribing of ONS and tube feeds at approved ACBS/NHS prices. That said, overall the procurement process has managed to extract good value for the health economy as a whole, with primary care also getting additional value from contracts such as discounted giving sets and free delivery. Overall though, in simple terms, secondary care has been driving the purchasing of these products and driving value for the whole health economy but primary care has been footing the bill! WHY WE NEED TO UNDERSTAND MALNUTRITION IN AN OUTCOME-DRIVEN NHS There is strong evidence for managing malnutrition and by doing so appropriately, it can deliver: • 27% reduction in admission rates and readmission rates1 • Reduce length of hospitalisation by 4.5 days2 • Reduce complications such as pressure ulcers by 19%3 and antibiotic use by 56%4 Moreover, results and reduction in costs can be realised in a very short time frame - months, in fact, not years. NICE recognises it as No. 3 of all of the NICE clinical guidelines that it has produced for delivering substantial cost savings? 5 WHICH PATIENTS ARE ONS AND TUBE FEEDS APPROPRIATE FOR? Whilst the evidence for the use of ONS is compelling, they can be subject to inappropriate use, wastage and stock piling. It is clearly in everybody’s interest to see them used appropriately. NICE recommends their use in high risk patients identified through MUST screening, although commissioners might want to prioritise certain groups such as those with COPD, dementia, pressure ulcers, people recovering from surgery and those with swallowing difficulties. ETF is used to feed patients who cannot attain an adequate oral intake from food and/or oral nutritional supplements, or who cannot eat or drink safely. The aim is to improve nutritional intake and so improve or maintain nutritional status. It is used most commonly in patients with dysphagia either because they cannot meet their nutritional needs despite supplements and/or modifications to food texture/consistency, or because they risk aspiration if they try to do so. Other indications for ETF include (not exhaustive) Post CVA, multiple sclerosis, Motor Neurone Disease, Parkinsons Disease and GI dysfunction or malabsorption.


HOW HAS SECONDARY CARE BEEN SPENDING PRIMARY CARE MONEY? - DESCRIPTION OF THE MODEL The current model consists of 4 elements across primary and secondary care (figure 1). This comprises tube feeds and ONS across primary and secondary care respectively. Existing contracts generally cover both ONS and tube feeds in secondary care and tube feeds in primary care (the darker shaded portion of the grid), with an expectation that primary care prescribing for ONS will also be for the contracted product, driven by choice in secondary care. The contracting process is generally led by secondary care and typically, ONS and tube feeds are heavily subsidised in secondary care – often supplied for a penny each! Suppliers then depend on continued prescribing of their products in primary care to recoup the heavily discounted prices in secondary care. Over the years, the competitive nature of this market has enabled NHS procurement teams to extract ever increasing value. For instance, many tenders for these contracts will require bidders to fund clinical posts (usually nurses or dietitians) and even staff training. The nurse teams are aligned to the NHS agenda i.e. work to get early discharge and prevent re-admission. In addition, prescription processing is provided, such as stock control to reduce wastage (including management to reduce prescribing, where appropriate), accuracy checks to ensure patients get the right treatments for safety as well as free delivery and associated equipment such as pumps. A list of product and service elements included in a typical contract is given in Figure 2. Figure 1: The Funding Model for ONS and Tube Feeding: The dark shaded areas represent what is typically included in the contract, whilst ONS in Primary Care (light blue) is not

Secondary Care Tube Feeds Secondary Care ONS

The Funding Model for Malnutrition

Primary Care Tube Feeds Primary Care ONS

WHY COMMISSIONERS NEED TO ACT NOW As we can see from Figures 1 and 2, the NHS has been getting great value when the model is viewed as a whole across the entire health economy. However, PCTs have been targeting ONS in isolation and the reduced spend here is threatening the future viability of this model. In fact, in addition to a general lack of awareness of the model amongst primary care commissioners, there is also a lack of awareness of the clinical and cost-effectiveness of ONS (when used appropriately), leading to an imbalanced approach of simply reducing or even stopping ONS use completely, rather than driving appropriate use that encompasses initiation of treatment in those with appropriate clinical need. If the current direction of travel continues, there is a real risk that certain contracts will no longer be viable as providers pull out of contracts or put their prices up and the health economy will be forced to pay more. On a more positive note, there is an opportunity for commissioners to take hold of the reins and re-focus the existing model; moving away from the existing paradigm which is a product procurement driven approach to a model that is commissioning led and QIPP-oriented. This is more likely to deliver appropriate clinical

Figure 2: What might be included in a typical contract Service component

Charge to secondary care

Charge to primary care

Tube Feeds


ACBS Approved price

Plastic giving sets



Deliveries (feeds and ancillary items) to patients




On Loan ( no charge)

On Loan ( no charge)

Out of hours phone helpline



Oral Nutritional Supplements


ACBS Approved price

Clinical Nurse Post (numbers stipulated in tender)



and financial outcomes (reduced avoidable hospital admissions and readmissions), whilst maintaining the excellent quality and value being delivered currently, especially relating to tube feeds. WHAT COMMISSIONERS NEED TO DO Although it is tempting to wipe the slate clean and re-balance the contracts so that primary and secondary care pay for exactly what each uses, the practical difficulties make this a complex option, at least to attempt it in one monumental step. The reality is that the model viewed in its entirety, works well across a whole health economy and starting from scratch could lead to increased costs overall. Having shared this model with commissioners, the unanimous view is that the most prudent approach would be to engage local commissioners, expert clinicians (especially dietitians) and the provider companies of nutrition products to work out the best model going forward. A commissioning-led solution could actually provide an opportunity to embed service specifications for malnutrition management within contracts of existing providers including GPs, community service providers and acute trusts. Below are some questions you should ask yourself about your local contracts. If you answer “NO” or “DON’T KNOW” to any or all of these, it is time to probe into your contract arrangements to make sure that you are fully aware of the value you are getting and to ensure your health economy is not spending more overall. In fact, by doing so it could enable you to obtain real improvements in clinical and cost-effectiveness... now that really is worth getting your credit card out for!

QUESTIONS FOR COMMISSIONER: • Do you know your current procurement arrangements? Who is your contract with? • What is included in the contract? Do you receive any value-added services, such as funded posts, rebates etc? • What is the total contract value and are you receiving value from it? When is your contract up for review?

This article was supported by an unrestricted educational grant by Nutricia Ltd. Nutricia are providing external facilitation and contract review meetings with key stakeholders to raise awareness and help you to understand your local arrangements. Please contact for more information.

MAY/JUNE 2012 | 17


Happy together

DR TIM DALTON, clinical chair of Wigan Borough Clinical Commissioning Group and COO Trish Anderson, take a big picture approach to commissioning. They tell JULIA DENNISON about their innovative integrated care model, and how campaigns like Breathless, which addresses asthma, COPD and heart failure under one pathway, help bring health and social care together


he integration of healthcare into the community is obvious the minute you set foot into the Wigan Life Centre, home to Wigan Borough Clinical Commissioning Group. The CCG’s HQ is located in a building that plays host to a number of different social and health care services and its open-plan office overlooks a public pool and fitness centre – so the local population is never too far out of sight. The physical structure of the building is symbolic of the CCG’s larger approach to integrating health and social care in a unique and forward-thinking manner. When I visit clinical chair Dr Tim Dalton and chief operating officer and interim accountable officer Trish Anderson, it’s April, the time when commissioning groups like Wigan Borough were just coming into shadow form. Dr Dalton sits on the commissioning board as lead clinician, while Anderson is lead manager – and both have high hopes for rolling out their innovative integrated care model to the local community. DOCTOR KNOWS BEST Dr Dalton considers himself a GP first and foremost, having worked in general practice in Wigan for 12 years prior to his post on the CCG board. His

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“raison d’etre”, he says, is training and quality. Indeed, his practice, Shakespeare Surgery, where he is a partner with two other GPs, was the first single-handed training practice in the North West and his team worked closely with the PCT to set up a group of clinicians focused on improving quality across the locality, particularly around pathway design and implementation. It was a natural progression for him to move on to practice-based commissioning, at a time when the Framework for Procuring External Support for Commissioners (FESC) process was underway. “It allowed the PCT to really engage with clinicians,” Dr Dalton remembers of PBC. “Historically, at that stage, we had been held at arms-length and we were part of the problem, not the solution, and that allowed us to get into the [commissioning] space.” As part of this process, a number of local practices started to group together to form groups covering around 50,000 patients each, which began meeting on a monthly basis. “[To date], GPs have been peers, but have been suspicious of each other,” Dr Dalton explains, “by getting into a room on a monthly basis and to talk and exchange ideas, it starts to build a different ethos of trust and cooperation.” SHARING AN UMBRELLA This cooperation and trust would become beneficial when those groups would merge to become five localities under Wigan Borough CCG. In the first wave of pathfinder applications, five localities in the Wigan area had applied to become separate CCGs, but were unsuccessful. Four of the five came together under a federated application for the third wave of pathfinders and it was accepted. The fifth locality – United League Commissioning – has since joined forces with Wigan Borough due to receiving a few red flags on its first gateway assessment. It’s been important to the ethos of the CCG to keep those locality groups under the larger umbrella brand, and they have been careful to formalise that federated agreement. “For us, CCGs are [built] around practices working together,” says Dr Dalton. “You can’t put 52 practices into a room; you can put 10 or 15 into a room and have some genuine dialogue.” A MANAGER WITH A DIFFERENCE Putting these ideas into play takes good management strategy, and this is where Anderson comes in. Her background is in health and local government, previously working for the council as a director of children’s services. She came over to work for the PCT as deputy to its chief executive, who was also heading up the local authority as well. She’s local too, having worked in Wigan for 25 years and knew many of the stakeholders already. Anderson, Dr Dalton and the rest of the CCG’s commissioning board felt it was absolutely imperative to treat the commissioning group as a new organisation, and not get hung-up on how things used to be under the PCT. This comes down to setting different value sets and cultural aspects inside the organisation, while putting quality, clinicians and patients at the heart of every decision. MORE THAN JUST PATIENTS The group is also very focused on integrating services across the entire spectrum of health and social care. This is an ambition they share with the local authority, which also happens to be housed on the same floor of the Wigan Life Centre, making it logically a lot easier for the CCG to collaborate with them on services. It also means that the people of Wigan are not just treated as patients by the CCG and residents by the local authority, but citizens who have a right to live comfortably. Integration lies at the heart of this ethos.

MAY/JUNE 2012 | 19


“If you’re going to make the whole system work,

within the financial constraints that all of us have, you can only do it if you integrate care”

“If you’re going to make the whole system work, within the financial constraints that all of us have, you can only do it if you [integrate care],” says Anderson, pointing to the fact that an aging population means many of the patients in the area will be using a number of different health and social care services. “Our commitment really is to get the integration working right the way through.”

FACT BOX CCG Wigan Borough PRACTICES 65 PATIENTS 320,000 EXECUTIVE BOARD 10 people, comprising five GP leads, a chair, an accountable officer and a chief finance officer and two laypeople. They are actively recruiting a secondary care doctor and nurse.

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STOP AND BREATHE One example of this integration of care and quality includes a scheme the Wigan groups started just over a year ago called Breathlessness, which looked at ways to integrate COPD, asthma and heart failure pathways for the many patients who have all three conditions. “We recognised the problem when people bouncing between three really good pathways with three really good teams weren’t getting better or were still ending up in hospital,” explains Dr Dalton. Around 18 months ago, the locality groups went back to their practices to come up with a solution. “We came up with a very different model,” he continues. “This was very much a facilitative way [of working], where we brought all the current providers into a space – that was the community teams, the secondary care teams, the GP teams – but we also brought patients, third-sector providers, finance and commissioning people into that space [too]. We started to thrash out a truly integrated service where people would have breathlessness as a problem and the team would help diagnose, manage and pass back. So it was very much about an empowering process and it equally linked into the social healthcare needs.” The model that came out of it was a diagnosis process and then a management process, which covered everything from smoking cessation to heating allowances, and therefore acts as an exemplary model of health and social care working closer together. The proof is in the pudding and the results from the Breathlessness pilot give that proof. As a result of the scheme, there was a reduction of hospital admissions in the area covered by the pilot compared to the rest of the patch, where admissions had actually gone up; the number of outpatients plummeted; the quality and accuracy of prescribing vastly improved – which has had a knock-on cost savings effect; and more importantly, the patients were happy with it. The CCG commissioned Ipsos MORI to survey the participating patients and the feedback has been very positive. “The patients have really started to understand what’s wrong with them and what they need to do when they get poorly,” explains Dr Dalton. “They’ve really started to be empowered to actually make a difference and that’s probably the biggest win from this. There’s all that financial stuff, but patients are actually in charge of what’s going on with them and are much more self-confident and that’s what’s led to the reduction of admissions because there isn’t the anxious, help-seeking behaviour because they know what to do.” This approach to the patient as a whole person is what makes commissioning in Wigan so successful. “Social care faces the same challenges and often the solution is the same for both sides of the process,” adds Dr Dalton. Indeed, it seems, if CCGs are to meet the Nicholson Challenge, they can’t do it without patients and social care on their side.

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dream team

The team at Durham Dales commissioning locality is making waves with its pathfinder work, implementing a number of innovative patient pathways despite a challenging geographic area. It’s no wonder they have been nominated for the BMJ Clinical Commissioning Team of the Year award. JULIA DENNISON speaks to project lead CLAIR WHITE to find out more


lair White and her colleague Vikki Reed are leading the way to better commissioning in Durham Dales. As the two project leads on the Durham Dales locality commissioning team, they lead pathway redesign, commission and decommission services under Durham Dales, Easington and Sedgefield clinical commissioning group, and are actively reducing unnecessary secondary care referrals by providing care closer to the patients’ homes.

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“When you mention

reduction everyone thinks it’s about rationing care, and it’s absolutely not; if we can provide all these services in primary care, it just should have an impact” Durham Dales recently merged with two other localities to become one CCG, but still actively commissions services on its own with the support of a strong team of clinical and managerial staff. Together, they recognised that a new, innovative model of care, built on robust evidence and based around patient-centred pathways could provide a solution to the area’s problems. TOUGH TERRAIN Durham Dales itself has a relatively stable population of around 90,500 patients, but covers a large, diverse geographical area, which brings its share of challenges. While the locality includes some small areas of urbanisation, it also encompasses many rural areas, which can be difficult for commissioners who have to provide services for isolated patients, often encountering transportation difficulties on the way. Meanwhile the cluster of 12 practices has a prevalence of poverty-related disease that is significantly higher than the national average in some cases. In the face of this adversity, the

Durham Dales team: Clair White, Vikki Reed, Dr Stewart Findlay, Laura Kirkup and Deborah Perry

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commissioning team maintains a selfproclaimed “can-do” attitude to moving services closer to patients. The group of practices achieved success in this area prior to the existence of clinical commissioning as part of a Department of Health-funded Integrated Care Organisation (ICO) pilot from 2009 to 2011. As part of the ICO, the Durham Dales teams undertook several successful work streams, eight of which have been developed further by the CCG since it gained pathfinder status, covering: care closer to home for diabetes and gynaecology; improving rural mental health pathways; improving mental health services for older people, focusing on dementia; vascular screenings in GP practices; better transport links; a fuel poverty scheme to encourage GPs to use Energy Savings Trust’s ‘hotspots’; an urgent care work stream; and a GP bed initiative in practices to help patient recuperation outside of an acute hospital setting. REDUCING REFERRALS When the Durham Dales Pathfinder CCG went live on 1 April 2011, its core aim was to reduce unnecessary GP referrals into secondary care by redesigning patient pathways, commissioning and decommissioning services and providing care closer to home. Early outcome measures suggest the pathfinder has been successful and is

reducing referrals into secondary care by more than the five per cent target in the Dales and by a significant amount overall for County Durham and Darlington. Activity commissioned to support the CCG has been vast and over 20 projects have been led and rolled out via the project leads and the practices. One commissioned pathway has been around diabetes, developing a consultant and specialist nurse-led community diabetes service in all 12 GP practices in Durham Dales. The CCG also entered into a partnership arrangement with a pharmaceutical company, which provided them with a dedicated diabetes health development manager (a former PCT employee) to support the rapid roll out and provide diabetes expertise. Another successful pathway focused on the diagnosis and management of IBS in primary care, resulting in better patient care by reducing unnecessary endoscopies and invasive tests needed in secondary care, which also saved a substantial amount of money for reinvestment elsewhere. It’s this pathway that White is most proud of. “I very much feel we’ve led the way,” she says of this area. “We took a leap of faith and just had a go and piloted it, which is what it’s all about.” As a result, there has been much interest in the health community around Durham Dales’s work on IBS and the outcomes it achieves. “I’ve seen the data on how many GI referrals wesent into secondary care this year when compared


to last year, and it’s significantly less, so it’s clearly having an impact,” says White. “And we’ve had huge campaigns on cancer, which is bound to make our referrals go up, so we know we’ve made a difference, and we’ve probably made a bigger difference than what we think.” Historically, Durham Dales was also one of the first localities in the country to bring specialist nurses into every general practice to run secondary care prevention clinics for cardiovascular disease and to look after patients with heart failure, and this continues today. Its original service was described by the Government’s former national director for heart disease and stroke, Sir Roger Boyle as “the gold standard to which all other areas should aspire”. More recently, the locality involved all of its practices in looking at the prevention of cardiovascular disease, predating the DH’s launch of its ‘Putting Prevention First’ initiative. They also developed the concept of a quality contract with the acute provider, community provider and mental health trust. This has allowed closer working between the locality and its provider colleagues and, again, this idea predated the Foundation Trust Standard Contract from the DH. STRONG LEADERSHIP These pathways would lead nowhere if it weren’t for a strong leadership team. The 12 practices in the Durham Dales have always worked closely together. For many years now, they have allowed their community nurses access to the IT systems and made full use of electronic path laboratory results and requesting of laboratory tests. Working relationships with local out of hours GP colleagues have been enhanced with the provision of shadowing opportunities in local practices, ensuring engagement between primary and secondary care clinicians. All groups meet monthly or bimonthly. At these meetings all current and developing projects and pathways are discussed in detail before attaining sign off by members, ensuring each project undergoes very robust governance. As chair, Dr Stewart Findlay ensures that all projects are patient care-focussed and

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clinically-led, while project leads, White and Reed, work alongside the Durham Dales practices to set priorities and develop commissioning intentions. In turn, these have been included in the locality’s five year strategy and the Durham Dales, Easington and Sedgefield’s ‘Clear and Credible Plan’, which will be instrumental in the CCG’s journey towards authorisation. A GOOD WORKING RELATIONSHIP Practice managers and GPs in the Dales have a very good working relationship with the commissioning team and this is demonstrated in many ways – information requests are dealt with in a timely fashion by practices, something which is essential and assists the project leads when they are developing pathways and service redesigns. Project leads attend all practice manager meetings and are considered to be integral members of the overall Durham Dales group of practices. Clinical leadership has been distributed to ensure engagement and clinical input in all areas and at all levels. All clinical areas have a patient representative attached to their forums and a consultant diabetologist, practice nurses and nurse specialists are attached to the diabetes pathway, while a local pharmacist leads on MURs and asthma for the locality. The group organises quarterly, soon to be bi-monthly, whole cluster educational events, which have grown in popularity over recent years and are now attended by upwards of 200 delegates. Speakers are sourced from around the country and all requests for topics are considered and, wherever possible, structured to practice needs at one of the events. These events have been so successful that there is now a waiting list for speakers wishing to attend. When I speak to White, she’s getting ready to attend the BMJ awards, where the team is nominated for clinical commissioning group of the year. Whether or not they come home with an award, they certainly deserve the recognition for their unrelenting ambition and dedication to improving care for their patients in the Dales. And there is no stopping them now: “We’ve got loads more ideas for this year,”

says White. Plans include expanding the IBS pathway to include IBD; introducing teledermatology into primary care, whereby GPs can take pictures of suspect moles, for example, and email them through to a consultant; ring-pessary fitting and changing in primary care; expanding the diabetes service; improving palliative care and stroke prevention; stepping up dementia screening and psychotic prescribing; implementing physiotherapy in all the GP practices and counselling services; and commissioning a primary care urology service. The team is also keen to reduce secondary care referrals by another five per cent this year. To do this, White believes all they need do is keep up the good work. “All of our primary care and community pathways should just make that achievable,” she says. “It’s not about rationing. When you mention reduction everyone thinks it’s about rationing care, and it’s absolutely not, but if we can provide all these services in primary care, it just should have an impact.” With this commissioning teams’ track record, it undoubtedly will.

FACT BOX CCG Durham Dales, Easington and Sedgefield PRACTICES 41 PATIENTS 280,500


Saving the NHS from bankruptcy PAUL ROBINSON analyses trends in hospital admissions, and offers starting advice on reducing both elective and emergency admissions in your area

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hoever you choose to believe about the extent of the national debt and the reasons behind it, the future impact on the NHS is inalienable. Nine tenths of healthcare treatment might take place in primary care but in terms of spend, hospitals care accounts for 52% of PCT expenditure. Analysis by healthcare intelligence firm CHKS shows that hospital admissions are still on the rise and could bankrupt the NHS – so what can be done to encourage the shift away from hospital care? A good starting point is to examine the increase in hospital admissions in more detail to see if that throws any light on what the possible drivers might be. The figures from CHKS certainly make disappointing reading for all those intent on moving more

Another factor affecting elective admissions is patient demand. Patients are becoming more savvy about their treatment options and as any GP will tell you, increasing numbers of patients are turning up to appointments with print-outs from the internet. Their expectations play a big part in elective referrals.

treatment into primary care. The analysis focused on the amount of growth from 2007/08 to 2008/09 and used the national Hospital Episode Statistics (HES). Analysis was carried out on both elective and nonelective admissions, both separately and combined. The overall combined headline figure was an average growth of 6.0 per cent across England. This compares to an average of 4.6 per cent across the preceding three years. Splitting the figures shows a 6.7 per cent growth in electives admissions and a five per cent growth in non-elective admissions.

the A&E target which stipulate that patients have to be admitted within four hours of arriving at A&E. This means that patients who may not necessarily have been admitted under the previous regime, are finding themselves admitted for relatively minor procedures and then discharged the same day. When looking at the growth in hospital admissions, you also have to look at the rest of the healthcare system. For example, the availability of out-of-hours GP services plays a role when it comes to emergency admissions. Continuing disquiet about GP out-of-hours GP services that surfaced most recently with national newspaper headlines following the death of a man in Cambridgeshire has inevitably had an impact on expectations. One hospital trust in the east of England recently pointed the finger at falling confidence in local out-of-hours services for its rise experienced in emergency admissions.

ELECTIVE ADMISSIONS As far as elective admissions are concerned, there are a number of reasons why they have increased faster than emergency admissions. First is the impact of the 18 week waiting time target. Figures for November 2009 show that 92.8% of all elective admissions met the 18 week target. The target has undoubtedly led to greater levels of activity as hospitals have attempted to get patients seen within the target time. Reduced waiting times themselves had an impact on activity levels as they reduce threshold for elective admission. In other words, as more patients are being seen with shorter waiting the greater the likelihood that the newly-diagnosed will be referred. GPs know the patients they refer will be seen relatively quickly.

“More hospital admissions runs the risk of taking all growth monies in future”

NON-ELECTIVE ADMISSIONS As for non-elective admissions, the analysis reveals that growth is nearly all in the number of patients discharged on the same day. This is often referred to as ‘zero length of stay’. This may be happening because of

TAKING ACTION So what can be done to reverse the trend? The researchers came across several areas in the UK where referral management programmes had been successful. The most successful ones were those that were set up by local GPs. There is mounting evidence that these programmes can reduce referrals – particularly first outpatient referral but less evidence that they can reduce the number of procedures carried out. One step that

practices can take to understand referral patterns is to benchmark themselves against other practices in the area. This can be done at speciality level and may be useful to have when discussing referral management with the PCT. Having GPs with specialist interests will also help to keep referrals down. Wellintegrated GPwSI services are nothing new but they are still worth considering as part of referral management. For non-elective admissions there are two strands. First is the work that can be done with patients with long-term conditions such as asthma. Identifying patients who are at risk of hospital admission and helping them to manage their treatment either at home, or in a primary care setting has been shown to be effective. One award-winning project of note is virtual wards in Croydon. Virtual wards copy the strengths of hospital wards: the virtual ward team shares a common set of notes, meets daily, and has its own ward clerk who can take messages and coordinate the team. The term ‘virtual’ is used because there is no physical ward building: patients are cared for in their own homes. Patients are ‘admitted’ to the award once they are deemed at high risk of hospital admission because of a long-term condition. Second, is a method that stops patients being admitted at the front door of the hospital. Very often this involves a GP triaging patients in A&E. This works because they have a slightly different approach to treatment because their first imperative won’t be to admit. Whatever you do, you have to understand the local drivers in the healthcare system and this means getting to grips with the statistics. This involves looking beyond your front door at other practices to see how you compare. Doing nothing is no longer an option. The increase in acute care costs has been restricting the PCT funds that are available for investment in other priority areas. Unless the growth in hospital admissions is addressed, it runs the risk of taking all growth monies in future years, and quite likely exceeding them which will effectively put the local healthy economy into deficit. Paul Robinson is head of market intelligence at CHKS

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Dementia is costing the UK economy more than ÂŁ25m per year. Two NHS trusts are doing something about it. COMMISSIONING SUCCESS finds out more

Working together to tackle dementia 30 | MAY/JUNE 2012


“In the next 20 years,

dementia will become a massive financial concern”

Dementia now affects more than 820,000 people in the UK, a number which is forecast to rise as the population ages. In fact 163,000 new cases of dementia occur in England and Wales each year – one every 3.2 minutes. This is a major issue that costs the UK economy more than £25m. Two Merseyside NHS Trusts are taking a new approach to tackling dementia – cases of which are expected to rise dramatically by 2020 – by forming a special network. Liverpool Community Health NHS Trust (LCH) and Merseycare NHS Trust are working together on a ‘clinical network’ which will pool the resources of both organisations and will mean that there is a single, clear pathway which will enable the early identification and treatment of patients with mental health needs. Local acute trusts will also have involvement in the network. Dave Jones, consultant nurse for older people for LCH, says: “Dementia is a huge, growing healthcare issue due to the changing demographics of the population. It is estimated that in the next 20 years, dementia care will become a massive financial concern, consuming billions of pounds – and potentially up to half of the NHS budget. “We need to make sure we are putting adequate systems and processes in place to support patients and carers to deal with dementia. At present on Merseyside there isn’t a clear single pathway for identifying and treating dementia patients. So, we are not really intervening with patients as early as we’d like. By pooling our knowledge and resources in this integrated way we can work more effectively and efficiently. “People with dementia are present in all of our care settings – in hospital, intermediate care units and care homes as well as out in the community. We all have some involvement in identification of patients and treatment planning , so dementia leads

in both organisations felt strongly that we should pool our services together and develop a more integrated approach. This is simply a new way of working. So for example, if a patient is recovering following a hip replacement operation and it is suspected that he or she has dementia, this can be followed up through use of the network.” The network currently has identified three main streams of joint working: a tailored care and proactive care model, care home support and the development liaison psychiatry to support Intermediate Care. The proactive care model, also known as tailored care, is a 12-week programme for patients with long-term conditions. Patients are identified to take part in this using health and social care data. This approach will identify patients with dementia as well as those suffering other conditions such as COPD and heart disease. Jones adds: “With regard to care home support, what we want is one integrated care home support team so an LCH nurse working in a nursing or residential home could simply call a mental health nurse if and when necessary rather than having to refer to mental health teams via GPs.” He continues: “The third element of the work, liaison psychiatry, also involves integrated working. Some patients in hospital beds have dementia and nursing staff need support with these patients. From 1st April 2012, there will be further developments regarding acute hospital liaison work going on. “The idea is that Merseycare NHS Trust has a bespoke liaison team working across Acute wards. Extending that concept, people in the intermediate care system –with a total of 101 beds –increasingly require mental health input. It would be great to have a liaison psychiatry team to help meet these patients’ needs.”

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Information for the nation For commissioning to work, CCGs have to be able to access provider information. Here are our top tips for joining up practice data


Encourage practices to present their information so that it will be as easily accessible as possible for the commissioning support officers who will be looking at it. Talk through your plans with the surgeries in your area to ensure they will be working along similar lines and establish a code of practice.


The right informatics system is essential if information sharing is to be a success. The ideal system will be simple and easy to use, while being compatible with a wide range of other systems, so that information can be shared across practices using different ones. The right system will enable clinicians across practices to make decisions based on robust and reliable data.


The sensitive nature of patient information, means that security is of paramount importance. All information should be encrypted and available through password access only. Seek advice from your IT service provider on the best ways to keep information appropriately safe. Backing up all information is particularly important as well, as exposure to other networks can leave yours more vulnerable to viruses and other security risks. Current trends are leaning towards cloud-based systems, although some still maintain that tape systems offer superior security.



The correct system will only be used to its full potential by staff who are adequately trained and aware of its full capabilities. In addition to being able to use the system quickly and efficiently, they should be aware of what to do in the event of data loss or similar emergencies relating to shared information. Staff should also be educated as to the reasons for sharing information and any circumstances in which it should not be granted.

If you opt to install a new system across the locality, there are bound to be problems, and the fact that so many other practices are involved, only increases the chances. Stay in touch with the practices’ managers and arrange regular feedback sessions to ensure that everyone involved is gaining maximum value from the process. It is equally important to schedule feedback from staff in order to establish that they are happy with the process and identify any glitches that they are experiencing.

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Telehealth has been deemed the solution to giving patients the power to self-manage chronic diseases. So what are the areas it can benefit the most and how much help has the Government provided commissioners so that they can start implementing it? CARRIE SERVICE investigates

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arly indications from government research show that, if used correctly, telehealth can deliver a 15% reduction in A&E visits, a 20% reduction in

emergency admissions, a 14% reduction in elective admissions, a 14% reduction in bed days and an eight per cent reduction in tariff costs. The Government also claims it demonstrates a 45% reduction in mortality rates. These figures were devised from the Whole System Demonstrator Programme, which ran from May 2008 to September 2010. The study monitored 6,191 patients and 238 GP practices for a minimum of a year across Cornwall, Kent and Newham assessing how using telehealth could benefit the NHS. It aimed to provide “a clear evidence base to support important investment decisions” and “show how the technology supports people to live independently, take control and be responsible for their own health and care”. The programme assessed how effective the use of telehealth and telecare were in treating chronic diseases; specifically diabetes, heart failure and COPD.

“Patients need to feel

empowered by the process, not overwhelmed, in order to truly engage and have confidence in its aims” THE ANSWER TO OUR PRAYERS? The programme was deemed a great success by Prime Minister David Cameron: “This is not just a good healthcare story,” he said, speaking just after the results had been published in December 2011. “It’s going to put us miles ahead of other countries commercially too as part of our plan to make our NHS the driver of innovation in UK life sciences,” he added John Dyson, chief executive of Telehealth Solutions, believes the savings will be vast. Commenting on the headline findings, he said: “There are enormous savings to be made from the implementation of telehealth that could be reinvested in

patient care. We estimate that these savings could be over £1bn per year which combined with the improvement in clinical outcomes demonstrated in the Whole System Demonstrator results makes the adoption of this approach a real and pressing necessity.” And it’s just as well, because Cameron aims to help three million people with the roll out of telehealth over the next five years, whilst simultaneously saving that infamous £20bn by 2015. But telehealth isn’t a quick fix, and should be approached strategically if it is to really have a positive impact on outcomes says Mike Evans, commercial director at the company: “Telehealth will only deliver real quality to both patients and clinicians if it is deployed properly to the right patients, with the right clinical protocols and has the right supporting technologies and services.” Knowing your local population and its specific needs from a commissioning point of view is key. When trying to implement a telehealth strategy, usability for patients should be high on the agenda, after all, it is they who will be managing it for the most part. “The technology has to be friendly and value [has to be] gained through its use,” says Evans. Allowing patients to be in touch with their GP and feel ‘in the loop’ with their progress is a good way of achieving this. Evans gives the following examples: “The ability of patients to receive feedback on their health when they have just completed a protocol; or engage with their clinician either through secure video conferencing or a messaging service; the ability to view educational videos; schedule hospital or GP appointments or have motivational/coaching interviews with a specialist triage nurse. All of these activities help the patient engage more strongly, adhere to their care plan, learn how to manage their condition more effectively and so derive the best value and experience from their telehealth system.” Patients need to feel empowered by the process, not overwhelmed, in order to truly engage and have confidence in its aims. SO, WHAT NOW? Should commissioners be looking at kickstarting investment in telehealth? The

Government was very eager to release figures revealing how much money the NHS could save through implementation, and around the time the headline figures were released, morale around telehealth in CCGs was high – a GP magazine poll showed that 83.93% of respondents voted ‘yes’ in response to whether or not they thought telehealth would benefit patients. But unfortunately the conversation with the Government around telehealth seemed to end once the headline findings had been released. After an announcement by the care services minister Paul Burstow in April this year that telehealthcare could save the NHS £1.2bn, GP magazine put in a freedom of information request with the Government to find out just exactly how these savings would be made. This request was blocked, with the department stating that it could “inhibit future policy delivery”. Jeremy Nettle from Oracle Healthcare and chair of Intellect Health Group, a forum for companies that supply the NHS, said in his blog on the subject: “The secrecy around this information does little to provide the NHS with the faith that it needs to consider telehealth as a real alternative to the systems that it currently has in place. Evidence for how telehealth can benefit the NHS is limited and the DH has yet to publish full results from its Whole System Demonstrator [WSD] trial of the technology.” He went on to question whether or not the full implications and logistical issues for implementing telehealth had really been considered and suggested that the Government had come to the conclusion that telehealth was a success through looking at evidence that might not be fully transferable: “It’s likely to be based on numbers of consultations or potential hospital savings and some of the small-scale pilots that have been done. Can we really scale up these figures?” It is true that the headline findings of the WSD were a little vague, and without specifics it’s difficult to see how the study will help. If CCGs are to get things moving, they need more than headline findings and empty comments; they need information and evidence.

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Procurement – the facts for GP commissioners

GP commissioners need to understand the ins and outs of procurement better, and many are keen to do so, which is a good thing as commissioning is here to stay. POLLY ELLISON speaks to solicitor RACHEL ROBINSON to find out what commissioning GPs need to know

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ith commissioning well and truly here, and the threat of reduction to GP income, GPs and their CCGs need to become better acquainted with the rules of procurement. Rachel Robinson, an associate solicitor from leading south west Solicitors, Foot Anstey, which specialises in healthcare matters, answers some questions on procurement. WHAT IS PUBLIC PROCUREMENT? Organisations (whether government bodies or other public bodies) that spend public money on goods, services and works (like building contracts) must follow strict rules on the process of advertising and awarding those contracts. These rules flow from EU directives and UK legislation – Public Contracts Regulations 2006) (SI 2006/5). The purpose is to ensure that contracts are awarded in fair, non-discriminatory open way. This is known as public procurement. WHY IS COMPLIANCE NECESSARY AND WHAT HAPPENS IF THE CONTRACTING AUTHORITY DOES NOT COMPLY? Compliance is necessary to limit the risk of challenges to the contract award, damages claims from bidders who have suffered loss as a result of any non-compliance, possible fines as well as adverse publicity and loss of public confidence. Suppliers (or potential suppliers) have a range of legal remedies available to them to keep the procurement process in check: the most significant is that the contract award is declared “ineffective” which usually means that the contract has to be re-awarded, or in some cases the process has to be re-run. Compliance also means that the end result of the authority’s procurement process should achieve value for money, and the best solution available as the right price. An unsuccessful supplier may obtain further information about the process not previously disclosed by the contracting authority, or challenge the process for non-compliance. Any benefit arising from a challenge should be balanced with the cost of making the challenge and any damage to the relationship with the contracting authority. DO THE RULES APPLY TO ALL PROCUREMENTS? Contracts with an aggregated value during the contract duration of over specific thresholds generally must comply with the full regime set out in the rules. These thresholds (for non-central government bodies) are: • £156,442 for goods • £156,442 for services • £3,927,260 for works. Central government contracts are subject to lower thresholds. However, some contracts above these thresholds do not have to follow the full strict rules. Contracts below these thresholds also do not have to follow the full rules, but must follow the general principles (see below). WHAT ARE ‘PART B’ SERVICES? Certain categories of services are not considered to have as significant European-wide concern as others, and so are exempt

from the full regime (even if are for values above the thresholds). These are known as ‘part B’ services and include legal services, hospitality, health and social care. As such, the procurement of clinical services does not have to be purchased under the full regime. The contract award for these services does, however, need to follow the general principles. These include: • transparency • equal and non-discriminatory treatment of potential bidders • advertising the contract in an appropriate, adequate medium • published clear, specific criteria (and the contract award based on those criteria) • and sufficient time for prospective tenders to respond to any invitation to tender.

“Any qualified provider (AQP) is a mechanism providing a list of possible accredited suppliers from whom services can be purchased, making the procurement process simpler and less risky for commissioners”

WHERE CAN I ADVERTISE FOR CLINICAL CARE SERVICE CONTRACTS ADVERTISED? The Department of Health has developed NHS Supply2Health, the mandatory primary care trust (PCT) procurement portal for clinical services providing a single source of information for advertisements where the PCT is the contracting authority. IS THERE ANY GUIDANCE TO HELP HEALTH PROFESSIONALS? The Department of Health publication, ‘Procurement Guide for Commissioners of NHS funded Services’ applies to CCG’s. Noncompliance may mean a referral to the Cooperation and Competition Panel (CCP) who have the power to investigate any action and make recommendations to the Secretary of State for Health. The CCP’s role is expected to transfer to Monitor under the new healthcare legislation. WHAT IS ANY QUALIFIED PROVIDER? Any qualified provider (AQP) is a mechanism providing a list of possible accredited suppliers from whom services can be purchased, making the procurement process simpler and less risky for commissioners. This model allows a range of providers to apply without conducting formal tender processes. Providers meeting the accreditation criteria will ordinarily be awarded a standard contract, but there is no commitment to purchase services or supply volume guarantee. The BMA has published guidance entitled ‘What we know so far. Choice and any qualified provider’, which is a useful tool for GPs, but also other health care professionals to get up to speed on this topic. There is much more to procurement than may, at first, be apparent. Whether GPs are working on CCGs or looking to start up their own provider company, they will have to understand the process. Most of the private provider companies or large NHS Trusts have ‘procurement teams’ that specialise in the tendering process, and who have templates already to ‘drop’ into the appropriate sections of the tender document. This means that these large organisations already have an advantage over their primary care competitors so the sooner GPs learn the ‘ins’ and ‘outs’ of procurement the better.

MAY/JUNE 2012 | 37


Don’t get held back

Establishing a clinically-led organisation without letting bureaucracy get in the way is a challenge CCGs face as PCTs let go. JULIA DENNISON looks at ways commissioners are cutting the red tape


ith the Health and Social Care Act, clinical commissioning groups are choosing their support from those who know. Commissioning support units (CSUs) are emerging like phoenixes from the flames of winding-down PCTs all over the country, and many new-found commissioners are taking solace in their expertise. There is a difference, however, between asking for advice and running the show, and if GP commissioners don’t take the reins in full, what is the point? CCGs now have a task on their hands to commissioning responsibly, while not getting caught in the red tape. GET THE RIGHT SUPPORT Philip Jones of Williams Medical Supplies says collaborating with the people with the right expertise will help ensure successful business case planning and reduce bureaucracy. “As we enter a new chapter in the evolution of primary care, clinical demands will be increasingly weighed against commercial considerations,” he says. ”While facts, figures, and quantifiable benefits offer nothing new, the level of detail required is expected to be greater than ever before, as is the pace at which it is required. Support is at hand for CCGs, not least by partnering with commercial suppliers who have the expertise and resources to help.” He also recommends having robust data systems in place for efficient data management and back office systems can make a big difference, as can having the right equipment. “Put patients first with the right equipment and the right support to reduce repeat visits,” he recommends. GET GOOD MANAGERS Karen Watkinson, assistant director of strategy, planning and assurance, Nottingham North and East Clinical Commissioning Group says allowing the GPs to commission services requires good managers. “There is real opportunity, but we do have a fairly enormous task ahead of us for everybody to get authorised by March of next year,” she says. “It’s around how those of us within the CCG work with and for the GPs to negotiate a path for them to make sure they’re able to do what they need to do. Basically, they’re not

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hampered with the bureaucracy; we deal with that for them.” Having worked for the PCT, what Watkinson finds most notable under clinically-led commissioning is seeing the GPs get involved in the pathway decisions in a real way. “Having the primary care clinicians in the room with the secondary care clinicians, so they are each able to put their point of view [forward], we are able to come to truly clinically-led decisions, as opposed to managers sitting in the room and fighting out over whose £10 it is,” she says. “The decisions are being made by the right people and then the managers are implementing those changes to the best of their ability.” She believes it is important for clinicians and managers to work together. “We are all working with a finite budget, so we have to make those decisions based on ensuring that that budget goes as far as it possibly can,” she say. “Between us we have to make the decisions about where that money is spent.” GET THE PATIENTS INVOLVED BEFORE THEY ARE PATIENTS Helen Northall, chief executive, Primary Care Commissioning (PCC) believes there is always less bureaucracy around the well than the sick, so part of the answer to cut red tape is to start the design of care pathways at prevention rather than treatment. “That approach goes hand in hand with self-care, responsible use of services and health education,” she adds. “All of which will only work, of course, if patients and the public are fully engaged in the planning and design of services and aware of the wider issues including the part they can play in staying well.” Watkinson has noticed patients being involved much earlier in her area of Nottingham, even around setting priorities for the CCG. The commissioning team even holds workshops where they go out into the public to draw people in and find out what they want out of their healthcare. “It is interesting, because their priorities do marry up with the priorities of the CCG,” she adds. “The general feel is we are very certainly all going in the same direction. By everybody being involved in that earlier stage, you would hope we would avoid the possibilities of conflict and it makes the difficult decisions easier because people can understand why those decisions are made.”

Commissioning Success May/June 12  
Commissioning Success May/June 12  

Commissioning Success