MAY/JUNE 2012

OFF TO MARKET 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

Welcome 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 editor@intelligentmedia.co.uk 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 mini-groups 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.

EDITOR

CONTENTS COMMISSIONING UPDATE

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

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

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

12 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

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

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

COMMUNITY CARE

28 Reduce and deliver Paul Robinson offers advice on reducing hospital admissions

30 Forget me not Working together to tackle dementia

INFORMATION AND TECHNOLOGY

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

34 Telehealth How CCGs can take advantage of telehealth for better outcomes

MANAGING COMMISSIONING

36 Understanding procurement Ways that CCGs can understand and procure even better

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

EDITORjulia.dennison@intelligentmedia.co.uk

ASSISTANT EDITORcarrie.service@intelligentmedia.co.uk

REPORTERgeorge.carey@intelligentmedia.co.uk

PUBLISHERvicki.baloch@intelligentmedia.co.uk

SENIOR SALES EXECUTIVEgeorge.petrou@intelligentmedia.co.uk

SALES EXECUTIVE gabriele.zaccaria@intelligentmedia.co.uk

DESIGNERsarah.chivers@intelligentmedia.co.uk

DESIGNER/PRODUCTIONpeter.hope-parry@intelligentmedia.co.uk

CIRCULATIONSnatalia.johnston@intelligentmedia.co.uk

Commissioning Success is published byIntelligent Media SolutionsSuite 223, Business Design Centre52 Upper Street, London, N1 0QHtel 020 7288 6833 fax 020 7288 6834email info@intelligentmedia.co.ukweb www.intelligentmedia.co.ukweb www.commissioningsuccess.comPrinted in the UK by Buxton Press www.buxtonpress.co.ukC

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NEWSWAVE 1 CCGS ANNOUNCEDThe NHS Commissioning Board Authority has confirmed the 35 aspiring clinical commissioning groups (CCGs) in the first wave of authorisation. These are: 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.

More training needed for managers

HEALTH ACT TO IMPACT DATAThe 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 bmj.com, 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

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 non-

geographically based CCGs, as well as some

responsibilities to local authorities, undermines

the availability of information and routine data

required to monitor the...health service.”

• Bassetlaw• Blackpool• Bedfordshire• Calderdale• Cumbria• Dudley• East & North Herts• East Leicestershire & Rutland• East Riding• Gloucestershire• Great Yarmouth & Waveney• Islington

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.

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.

Newark takes a breath of fresh air

LOCAL NEWS

• 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

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SEND IN YOUR STORIESWe are always looking for local commissioning news. If you have a story to share, email editor@intelligentmedia.co.uk.

CLINICAL CORNER

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.

NAO CONDEMNS DIABETES CARE

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.

Sunderland Men’s Health Network reaches out to men in the local area

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.

LOCAL NEWS

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

NHS South of Tyne and Wear uses technology to monitor LTCs

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 long-

term 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.”

LOCAL NEWS

20-22 JuneNHS Confederation Annual Conference

and Exhibition

Manchester Central Convention Complex

conference.nhsconfed.org

DIARY

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

Clinical 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 VALUESClinical 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 (http://www.rcgp.org.uk/centre_for_commissioning.aspx)

“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”

UPDATESHOW PREVIEW

08 | MAY/JUNE 2012

CommissioningShow 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

Registration 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.

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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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 CCGSSetting 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 CommissioningShow.co.uk.

UPDATESHOW PREVIEW

10 | MAY/JUNE 2012

LIST OF SPEAKERSPlenaries, 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 THERELondon 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 BOOKFree tickets are available for readers of Commissioning Success magazine. To book yours, quote special code “CSFree” at check out on http://www.commissioningshow.co.uk/

MAY/JUNE 2012 | 11

UPDATESHOW PREVIEW

UPDATECOMMENT

12 | MAY/JUNE 2012

AUTHOR BIORoger Hymas is a former MD of Bupa and director of commissioning for Hampshire PCT. He is also the founder of the Commissioning Community website, www.commissioningcommunity.co.uk

The future of theNHS? 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

So, 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

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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 health-

care: 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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14 | MAY/JUNE 2012

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.

“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”

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

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.

MAY/JUNE 2012 | 15

UPDATECOMMENT

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.

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 self-

interested 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

SPONSORED FEATURENUTRITION PRODUCT FUNDING

16 | MAY/JUNE 2012

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

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.

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, E5445. NICE Cost Saving Guidance. April 2012 http://www.nice.org.uk/usingguidance/

benefitsofimplementation/costsavingguidance.jsp

SHAILEN RAO, MD SOAR BEYOND LTDSERVICE PROVIDER OF MEDICINES MANAGEMENT SERVICES TO PCTs AND CCGs.

MAY/JUNE 2012 | 17

SPONSORED FEATURENUTRITION PRODUCT FUNDING

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.

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

and financial outcomes (reduced avoidable hospital admissions and re-

admissions), 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!

Service component Charge to secondary care Charge to primary care

Tube Feeds 1p ACBS Approved price

Plastic giving sets 1p 1p

Deliveries (feeds and ancillary items) to patients

Free Free

Pumps On Loan ( no charge) On Loan ( no charge)

Out of hours phone helpline Free Free

Oral Nutritional Supplements

1p ACBS Approved price

Clinical Nurse Post (numbers stipulated in tender)

Free Free

Figure 2: What might be included in a typical contract

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 info@soarbeyond.co.uk for more information.

Secondary Care Tube Feeds

Primary Care Tube Feeds

Primary Care ONS

Secondary Care ONS

The Funding Model for

Malnutrition

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

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?

IN ACTIONCASE STUDY

18 | MAY/JUNE 2012

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

The 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

MAY/JUNE 2012 | 19

IN ACTIONCASE STUDY

“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.

IN ACTIONCASE STUDY

20 | MAY/JUNE 2012

“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.”

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.

“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”

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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IN ACTIONCASE STUDY

22 | MAY/JUNE 2012

The dream team

Clair 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.

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

IN ACTIONCASE STUDY

24 | MAY/JUNE 2012

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

commissioning team maintains a self-

proclaimed “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

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

“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”

IN ACTIONCASE STUDY

26 | MAY/JUNE 2012

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 bi-

monthly. 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

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

COMMUNITY CAREREDUCING ADMISSIONS

28 | MAY/JUNE 2012

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

MAY/JUNE 2012 | 29

COMMUNITY CAREREDUCING ADMISSIONS

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

Whoever 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

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 non-

elective 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.

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.

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.

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

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.

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. Well-

integrated 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

COMMUNITY CAREDEMENTIA

30 | MAY/JUNE 2012

Working together to tackle dementia

Dementia is costing the UK economy more than £25m per year. Two NHS trusts are doing something about it. COMMISSIONING SUCCESS finds out more

MAY/JUNE 2012 | 31

COMMUNITY CAREDEMENTIA

“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 fore-

cast 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 work-

ing 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 iden-

tification 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 chang-

ing demographics of the population. It is es-

timated that in the next 20 years, dementia

care will become a massive financial con-

cern, 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, interme-

diate 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 sus-

pected 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 hos-

pital beds have dementia and nursing staff

need support with these patients. From 1st

April 2012, there will be further develop-

ments 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, peo-

ple 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.”

INFORMATION TECHNOLOGYTOP TIPS

32 | MAY/JUNE 2012

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

PRESENTATIONEncourage 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.

RIGHT TOOLSThe 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.

SECURITYThe sensitive nature of patient information, means that secu-rity 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 net-works 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.

TRAIN STAFF The correct system will only be used to its full potential by staff who are adequately trained and aware of its full capabili-ties. 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 informa-tion. Staff should also be educated as to the reasons for shar-ing information and any circumstances in which it should not be granted.

REVIEW 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 ev-eryone 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.

INFORMATION TECHNOLOGYTELEHEALTH

34 | MAY/JUNE 2012

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

MAY/JUNE 2012 | 35

INFORMATION TECHNOLOGYTELEHEALTH

Early 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.

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 kick-

starting 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.

“Patients need to feel empowered by the process, not overwhelmed, in order to truly engage and have confidence in its aims”

MANAGING COMMISSIONINGLEGAL

36 | MAY/JUNE 2012

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

MAY/JUNE 2012 | 37

MANAGING COMMISSIONINGLEGAL

With 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.

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. Non-compliance 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.

“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”

MANAGING COMMISSIONINGADVICE

38 | MAY/JUNE 2012

Don’t get held backEstablishing 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

With 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

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.”