Commissioning Success Mar/Apr 2012

SUPPORTING EXCELLENCE IN HEALTHCARE

MARCH/APRIL 2012

Welcome to the inaugural issue

WHAT’S ON THE AGENDA?

The Clinical Commissioning Coalition on the future of commissioning

COMMISSIONING IN ACTION

CCG leaders share their stories

DATA MANAGEMENT

Why it will make or break commissioning

Editor’s letter

CONTENTS COMMISSIONING UPDATE 4

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

7

Comment The Clinical Commissioning Coalition’s Charles Alessi on the localism agenda COMMISSIONING IN ACTION

W

elcome to the inaugural edition of Commissioning Success, the new, bi-monthly magazine for clinical commissioners.

It seems like every time you turned on the TV before the passage of the health bill through Parliament, it was being scrutinised. As participants in clinically-led commissioning, the changes to the NHS it describes are nothing new – in fact, commissioning is an inevitability you’ll have known about for two years come July, and it’s something you’ll be taking on in shadow form this month.

Although the health bill has only just passed, real decision-making has already fallen on the heads of commissioners with tangible budgets to boot. With this in mind, we decided there was no time like the present to launch. Like it or not, under the watchful eyes of clinical commissioning groups, commissioning is here.

These CCGs will need help. This will come in the shape of commissioning solutions from the Government and private companies alike. Readers of Practice Business will know our background and expertise lies in supporting healthcare management excellence. In this new publication, we aim to sort the wheat from the chaff in this gold rush of opportunity to help commissioners do their jobs.

When explaining GP-led commissioning to The New York Times, David Furness, head of strategic development at Social Market Foundation, used the analogy of a restaurant. “It’s like getting your waiter to manage a restaurant,” Furness said. “The government is saying that GPs know what the patient wants, just the way a waiter knows what you want to eat. But a waiter isn’t necessarily any good at ordering stock, managing the premises, talking to the chef – why would they be? They’re waiters.” Enter good commissioning managers.

Think of this magazine as your guide to managing commissioning, whether you’re used to it or not. Anyone who will be commissioning will need a little help to make the right decisions. It’s going to be hard work, but healthcare workers have never been put off by a challenge.

8

Case study Nottingham City CCG passes the first stage of authorisation with flying colours

16

Interview Dr Ann Bowman, and manager Louise Giles of Greater Preston CCG COMMUNITY CARE

22

Comment Primary Care Commissioning Commissioning’s Julian Patterson on why Right Care is science not magic INFORMATION AND TECHNOLOGY

26

Data management Why it will make or break commissioning

28

Seven steps for successful data mining The right way to collect information MANAGING COMMISSIONING

30

Commissioning support What’s out there, who to speak to and who to ask

32

Legal The perks and pitfalls of procurement in commissioning

34

Top tips Becoming a better commissioner

CONTACT US

EDITOR

EDITOR julia.dennison@intelligentmedia.co.uk

SALES EXECUTIVE gabriele.zaccaria@intelligentmedia.co.uk

ASSISTANT EDITOR carrie.service@intelligentmedia.co.uk

DESIGNER sarah.chivers@intelligentmedia.co.uk

REPORTER george.carey@intelligentmedia.co.uk

DESIGNER/PRODUCTION peter.hope-parry@intelligentmedia.co.uk

PUBLISHER vicki.baloch@intelligentmedia.co.uk

CIRCULATIONS natalia.johnston@intelligentmedia.co.uk

SENIOR SALES EXECUTIVE george.petrou@intelligentmedia.co.uk

Commissioning Success is published by Intelligent Media Solutions Suite 223, Business Design Centre 52 Upper Street, London, N1 0QH tel 020 7288 6833 fax 020 7288 6834 email info@intelligentmedia.co.uk web www.intelligentmedia.co.uk web www.commissioningsuccess.com Printed in the UK by Buxton Press www.buxtonpress.co.uk

UPDATE NEWS

NEWS Health bill becomes law The Health and Social Care Bill was finally passed by the House of Lords and is set to become law before Easter. MPs will then consider the amendments to the bill as agreed by the Lords.

The act will see PCTs and SHAs abolished and budgets put in the hands of GP-led clinical commissioning groups.

The health bill has been a point of contention across parties and throughout the healthcare sector, as the GPs prepare to take control of £60bn of the NHS. According to Prime Minister David Cameron’s spokesperson, there was “cross-

party banging” of the table at cabinet to mark the imminent Royal Assent for the legislation. He told the BBC that it would become law before Easter Recess.

Unions said they would continue to dispute the bill even after it becomes law.

The RCGP says it will help the Government implement the changes, despite originally opposing it.

Chair Dr Clare Gerada said that although they still oppose the bill itself, they believe that they must cooperate with the Government for the good of the patients and the NHS.

04 | MAR/APR 2012

vs

“Our plans will harness the expertise of local doctors and nurses, who know better than anyone what their patients need.”

The Department of Health’s response to the BBC

84.2%

Percentage of CCGs dissatisfied with the roll-out of the commissioning support programme

20%

Portion of CCGs that decided to use their local PCT cluster support offering because they were too busy to explore alternative arrangements

(Source: CCC)

Former NHS chief Lord Crisp, speaking out about the Health Bill on BBC Radio 4’s show The World

New information tools designed with GPs for general practice and clinical commissioning groups are set to redefine how data is used to manage local health economies.

NHS North of Tyne has developed the RAIDR (Reporting Analysis and Intelligence Delivering Results) system (pictured), which illustrates health information through a series of dashboards. This includes secondary care data as well as primary care data from GPs. Meanwhile, nearby NHS South of Tyne and Wear (SoTW) has deployed CCG+, another business application set to support CCG information requirements.

Survey reveals dissatisfaction with commissioning support

THEY SAID

“I think it’s a mess, is my straightforward view of it.

I think it’s unnecessary in many ways, and I think it misses the point.”

CCGs launch own support tools

UPDATE NEWS

LOCAL NEWS

PICTURE STORY

The Duke of Gloucester unveils the plaque at the official opening of the multi-million pound Cleadon Park Primary Care Centre and Library in South Shields.

LOCAL NEWS

South Tyneside healthy workplace scheme encourages local businesses to sign up Staff at local businesses in South Tyneside “Free advice and information is also are able to access a range of health initiatives available on a range of health topics including under a new local scheme. alcohol, sexual health, healthy eating, exercise NHS South of Tyne and Wear, working and stress,” she added. on behalf of South Tyneside Primary Care An event was held at the Town Hall in Trust (PCT), South Tyneside Council, local South Shields to recognise new businesses businesses, and representatives from the that have signed up to the Workplace voluntary sector have teamed up to form the Alliance which was attended by Tyne and Workplace Health Alliance in South Tyneside Wear Marine, Millennium Conveyor Services, to improve local workplace health.

Future Strategies Consulting, Energy Services Yvonne Hudson, health improvement North East and Groundwork South Tyneside practitioner at NHS South of Tyne and Wear, and Newcastle. working on behalf of South Tyneside PCT, said: “A number of businesses and workplaces across the borough have been involved in health initiatives for their staff who have been able to access a range of health initiatives within their workplace, including NHS Health Checks, NHS stop smoking services, Geoff Ford, chair of the South Tyneside Manufacturing Forum health trainers and selfwith Yvonne Hudson of NHS South of Tyne and Wear care courses.

Green for go as CCG gears up for authorisation NHS Nottingham City CCG passed the first stage of the authorisation process last month with flying colours.

The configuration risk assessment is the first stage of the process towards authorisation for emerging CCGs and is intended to help CCGs understand whether their current proposed arrangements are likely to meet the criteria defined in the Health and Social Care Bill, understand any risks associated with the proposed arrangements and give time to consider how to manage these risks.

NHS Nottingham City CCG has been rated ‘green’ on a traffic light system for each of the four risk elements: CCG boundary/population; local authority boundary; impact of size; and member practices.

“We are delighted with the outcome of this assessment,” said COO Dawn Smith. “It is further confirmation that we have the right foundations in place to establish a strong and successful CCG.” See p8 for more on NHS Nottingham City

CLINICAL CORNER HEART ATTACK PATIENTS Emergency hospital admissions drop by a quarter while death rate nearly halves in a decade Hospitals in England have seen the annual number of emergency admissions for heart attacks among patients aged 35 to 74 drop by more than a quarter in a decade and the death rate nearly halve, according to a recent NHS Information centre report.

Emergency admissions fell from 42,400 in 2000/01 to 30,600 in 2009/10.

During the same period, the death rate for within 30 days of an emergency admission for heart attack almost halved; dropping from one in 11 to one in 20.

SEND IN YOUR STORIES

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

MAR/APR 2012 | 05

UPDATE COMMENT

The defining point in the reform agenda DR CHARLES ALESSI from the NHS Clinical Commissioning Coalition gives his view of the commissioning agenda and why acting the dodo never works

“The new localism

agenda allows CCGs, with our local populations, to deliver better and more relevant care”

AUTHOR BIO Alongside his role as a senior member of the NHS Clinical Commissioning Coalition and chair of the NAPC, Dr Charles Alessi is a senior GP partner of the Churchill Practice in Kingston upon Thames.

T

he relationship between the citizen and state is undergoing a significant change and this is exemplified nowhere more acutely than in healthcare. Relationships between clinicians, patients and populations, which were once robust and secure, are now becoming more tenuous, and, in some instances, fractured. The trust, which formed part of that relationship, was once never questioned, and the underlying mutual respect is now no longer so evident.

A state of malaise has existed for some time.

It would be invidious to point fingers at where the responsibility for this lies, but the very wide availability of immediate information via the internet is a significant factor.

It is no surprise there is a disconnect between what is said about health and how it is perceived.

If this disconnect is applied to the difficulties we are having around the reconfiguration of hospitals in England, it is no surprise that the wrong end of the argument receives most air time. But is there anything about the present reforms, which offers more hope than their precursors?

LOCAL IS THE WAY I believe the new localism agenda allows CCGs, with our local populations, to deliver better and more relevant care. We need to enjoin them in the delivery of health and social care; localism shows the way. Where local relationships are established, conversations about the design and delivery of healthcare have far greater impact with connected and empowered groups of people, who, with their local clinicians, are leading the desired changes. Add to this, the local democratic mandate, which CCGs’ relationships with local authorities will bring, then we can begin to see the strengthening of grassroot relationships supporting the transformation of care locally. Accountability is one of the most discussed areas of health policy internationally; localism shortens the line and enables it to succeed.

which acknowledges the need for prioritisation of available resources within a population defined envelope, rather than the attribution of blame on other sectors of the local care system. We need to move away from the tribalism which exists, and mirrors old class systems. It has no place within the instantly connected working practices of the 21st century.

INDIVIDUAL NEEDS Finally, the last and most important ingredient to success is the population, and the individual.

Both need to be genuinely in a position of control of their destiny. They need to own their medical records, not merely gain access to them, to ensure they are the key determinant of the model of care they receive.

We are at the latest defining point in healthcare, with the NHS compared to a living organism; here three species come to mind; humans, who have evolved and adapted to the environment and predation; the dodo, which failed to do so and became extinct; and, the third, which is largely unchanged over thousands of years, and has survived despite predation and environmental change, is the cockroach. It would be a gargantuan tragedy for the NHS to be perceived as a pest, in need of extermination to prevent it becoming a barrier and impediment to change.

A TRUTHFUL NARRATIVE Another essential component to assist in such transformation is a shared and truthful narrative,

MAR/APR 2012 | 07

IN ACTION CASE STUDY

LEADING EXAMPLE

by

NHS Nottingham City CCG has passed the first stage of the authorisation process with flying colours.

Commissioning Success presents an overview of the CCG, including studies of some of the projects its executive team has implemented locally

08 | MAR/APR 2012

IN ACTION CASE STUDY

NHS NOTTINGHAM CITY CCG: AN INTRODUCTION Recent government policy has revolutionised NHS commissioning and for GPs and managers alike there has been much to digest and put into action. Thanks to shared boundaries and good partnerships with the local authority, well-developed practice based commissioning localities and a passionate clinical and commissioning workforce, the NHS Nottingham City Clinical Commissioning Group (CCG) has been in a strong position from the off.

Named as a second-wave pathfinder by the Department of Health in February 2011 and one of the first to be given full delegated authority from the PCT board in April 2011, the CCG is now focused on working towards full authorisation by 2013.

The CCG’s approach of taking its four PBC clusters forward within a single CCG has proved highly effective in encouraging practice engagement and local innovation, while allowing risk sharing and developing a single commissioning support team. The early success achieved in a deprived innercity area with over 60 practices is testament to the CCG’s strong leadership and robust governance. Now, with a clear focus on patient care, this dynamic and responsive organisation is embracing the exciting opportunities presented by the new world and making a name for itself as one of the leading CCGs in the country.

LEADERSHIP IN ACTION The keystone to establishing the NHS Nottingham City CCG has been recruiting a strong and committed leadership team. Nine local GPs, representing all areas of the city, were appointed to the executive committee (including four GP-elected locality chairs) and brought a wealth and diversity of local knowledge. The GP executive team includes clinicians who are passionate about mental health, drug and alcohol misuse, student health, emergency care, long-term conditions, improving patient pathways and reducing health inequalities, and each has taken lead clinical responsibility for at least one key commissioning area. All have relished the opportunity to use their understanding of the needs of local patients to full commissioning effect to ensure services in Nottingham are relevant and responsive enough to meet those needs.

They also appreciate that in order to achieve their aims, they need to have an excellent and experienced management team.

Alongside the GP leadership, the CCG is led by Dawn Smith, who was previously director of delivery and performance at NHS Nottingham City PCT and has a strong background in primary care commissioning.

Smith was appointed chief operating officer for the CCG in February 2011.

MAR/APR 2012 | 09

IN ACTION CASE STUDY

She is supported by Terry Allen as director of finance and Maria Principe as director of cluster performance. Allen previously held the same post in the PCT and Principe was instrumental in establishing practice-based commissioning in Nottingham City.

In order to ensure that the strong clinical foundation of the organisation was supported to take forward its new commissioning responsibilities, the GP executive members were put through an intensive development programme before receiving delegated commissioning budgets and responsibilities from the PCT Board on 1 April. The programme was also opened up to other non-exec GPs to ensure an effective first step to sustainability and succession planning. It included sessions on the characteristics of an effective board, understanding organisational governance, successful financial management, procurement processes, contracting and performance management, making partnerships work, using public health skills and analysis to drive and target effective commissioning, prioritisation of investment and the QIPP challenge, influencing and negotiation skills, and media handling.

The programme developed the GPs’ skills in working together and thinking as leaders of a pioneering new organisation rather than working independently as before. It was rated extremely highly

by GP participants and by the CCG’s educational lead, Dr Alastair McLachlan, who commented: “It was excellent with some highly articulate and thoughtprovoking sessions. As someone who has been involved in devising educational events I was very impressed.” The CCG will now build on this solid foundation and work to develop a long-term organisational development plan.

GOOD GOVERNANCE Terms of engagement have been developed to govern relationships between the constituent practices within the CCG and to support the CCG in undertaking clinical commissioning and achieving formal authorisation as an independent statutory organisation. This agreement details the organisation structure with the governance committee as its governing body. Established committees accountable to the governance committee are: n The prioritisation and QIPP committee – leading the organisation in prioritising commissioned healthcare, while ensuring robust and consistent investment and disinvestment decisions. The committee considers complex commissioning issues and ensures the appropriate public

10 | MAR/APR 2012

involvement and consultation in investment and disinvestment decisions with due regard to equality considerations. n The quality improvement committee – providing assurance on the quality of services commissioned and promoting improvement and innovation in treatment safety, effectiveness and experience. n The risk and assurance committee – ensuring robust risk management and assurance in relation to equality and diversity, information governance and data protection, business continuity, corporate social responsibility, and health, safety and security.

CLINICAL ENGAGEMENT It was very clear that for the CCG to succeed, constituent practices needed to truly engage with and support the new organisation and its vision. Regular locality board meetings were already wellestablished as part of PBC, but engagement and communication needed to be much deeper and more effective. A monthly newsletter called Connect, now goes out to GP practices, NHS managers and partner organisations to keep stakeholders in touch with progress, challenges and successes.

Articles cover organisational development, commissioning, good practice/advice and include executive team contact details to encourage GPs to get in touch and feedback their thoughts and innovations.

As part of engaging with constituent practices the NHS Nottingham City CCG organised two large-scale GP engagement events that proved to be a successful way of facilitating discussions and gaining feedback from practice members on key issues about the development of the organisation. At least one GP member from each practice was asked to attend as a representative with other practice members including practice managers and nurses also invited, offering all stakeholders the opportunity to voice opinions. Issues discussed at the events included future intentions for clinical commissioning and the impact on GPs, the clinical commissioning model for Nottingham City, the vision for the CCG, the terms of engagement and budgetary responsibilities for commissioning. Attendees also put forward their ambitions for the type of organisation the CCG should aspire to be and word clouds captured the feedback.

One significant and particularly effective innovation has been a programme of peer-led practice visits to support practices and encourage them to get involved and help the organisation achieve its strategic aims. The executive team is visiting each practice using a template format that includes the added benefit of helping practices achieve commissioning

Sir David Nicholson visits NHS Nottingham City CCG last November

“NHS Nottingham City

CCG has taken great strides forward since April 2011, establishing itself as a sustainable, effective and dynamic organisation, committed to working with its patients and partners to achieve better health outcomes for the population of Nottingham City”

IN ACTION CASE STUDY

Quality and Outcomes Framework (QOF) points. An A5 summary booklet was also produced to help the practices understand the commissioning QOF process and what was required of them to ensure success individually, for the CCG and for the wider health community.

The practice visits cover budget performance, acute admissions, the clinical advisory service (integrated triage and support), prescribing activity and care pathways, and practices are encouraged to come up with ways to improve the service they offer to patients and their journey through the system. The ethos is encouraging and supportive rather than critical and the response from practices has been overwhelmingly positive. The CCG is also running peer review sessions that will not only help practices with their commissioning QOF achievements but will also share best practice and learning from these visits.

and prevent an admission to hospital and 119 patients (11%) to prevent admission to a care home. Feedback from patients is very important and every service user completes a simple questionnaire to help evaluate success. So far there has been 100% user satisfaction. The service is continuing to build on its success by working with partners to support more people out of hours and take referrals directly from the ambulance service.

Estimated savings for the CCG so far are just under £1.5m.

THE QIPP AGENDA A range of initiatives are ensuring that the CCG is driving up quality, preventing illness, improving productivity and harnessing innovation. While cost improvements are critical to managing tighter NHS budgets, the CCG has placed a huge emphasis on ensuring that service change is also quality driven and improves the patient experience. The following case studies provide examples of QIPP initiatives delivered by the CCG:

The Community Neurology Service (CNS) is an integrated health and social care service that provides a multidisciplinary and multiagency approach to individuals with long-term neurological conditions (LTNC). There are strong links with secondary care including specialist nurse involvement within neurology clinics.

This integrated approach is one of the first in the country and Nottingham City is seen as leading the way in CNS service development. The service was developed following a detailed review of services available in the community for people with LTNC and taking into account feedback from patients, carers, and voluntary sector organisations. These relationships have developed throughout the implementation of the service to ensure a seamless and coordinated approach to patient-centred care.

The Crisis Response service includes a nurse, physiotherapist, occupational therapist, social worker, in-reach worker and trained rehabilitation support workers, bringing together existing health and social care services in an innovative and integrated way. The service helps individuals at crisis point, whether due to a physical health-related problem such as falling, or a social care issue, such as the breakdown of care. It offers the appropriate level of support, responding within an average time of two hours 45 minutes (maximum of four hours), to prevent an admission to hospital or residential care. Available seven days a week, the team provides assessment and up to four visits a day for up to 48 hours following a crisis. It can provide rehabilitation support, order equipment or initiate social care – allowing patients to remain in their own home and promoting independence while the appropriate care and support is arranged.

The Crisis Response service received 1,091 referrals in the first year; of these 972 patients (89%) were referred to try

Reducing emergency department (ED) attendance and admissions is a key priority for the CCG and a range of initiatives are now being used to encourage behaviour change from practices and patients. Resource packs have been sent to all 62 Nottingham City practices, which include materials to display and give directly to patients focusing on ‘get the right treatment’ messages and promoting the NHS 111 phone number for urgent care, for which Nottingham City is a pilot. These packs are supported by letter templates for practices to use in contacting all patients who have attended the emergency department more than five times in six months. The CCG has worked with acute colleagues to strengthen the primary care stream at the ED front door with more staff and a patient pathway focus. Two key successes have been negotiating for an ED consultant to always be available until 2am, and developing an innovative ‘observation unit’ in ED with a CQUIN target adopted to support and drive the process.

MAR/APR 2012 | 11

IN ACTION CASE STUDY

A community in-reach pilot has just been launched with Nottingham CityCare Partnership (community provider), Nottingham City Council and Nottingham University Hospitals NHS Trust to streamline and improve patient discharge. The pilot focuses on an orthogeriatric ward and aims to coordinate and facilitate early, safe and effective discharge from hospital, to ensure that all patients’ rehabilitation potential is met and to see fewer patients discharged directly into long-term care.

The CCG’s significant success in the first two months is encouraging with 37 patients reviewed in July and 23 discharged and a further 31 discharged in August. The length of stay on the ward is down from 15 days to seven.

PARTNERSHIP WORKING WITH STAKEHOLDERS The CCG has fully engaged with the local authority in establishing an effective health and wellbeing board to ensure that joint commissioning priorities are identified and driven forward. The COO, chair and two additional GP executives will represent the CCG on the board and will be actively involved in producing the joint strategic needs assessment for the City as well as a joint health and social care strategy.

CCG representation of this level will ensure effective liaison with the NHS Commissioning Board and productive engagement with local stakeholders. This will establish two-way communication channels so that debate from the health and wellbeing board is taken back to and informs local authority and CCG decisionmaking forums.

Jane Todd, chief executive of Nottingham City Council, supported the CCG’s application for pathfinder status, saying: “We are pleased that a proposal can be brought forward that ties in with our administrative boundary as this will allow a continuing focus on developing joint commissioning and integrated arrangements across health and local authority services. We welcome the opportunity to foster relationships with the city’s GPs, many of whom have made significant contributions beyond their practices to work with us on key initiatives in community regeneration, the health of young people and supporting marginalised and vulnerable groups. We look forward to developing a positive relationship with the commissioning consortium and believe it offers us the best chance to continue to develop the good work done by NHS Nottingham City.”

Another area of effective partnership working is a recent review of mental health third sector provision, aiming to improve

12 | MAR/APR 2012

the support pathway and develop a new integrated model of support for service users and carers. The process involved mapping existing provision and then engaging with stakeholders including service users and carers, joint commissioners, service providers and GPs. A consultation event was attended by over 100 stakeholders. A new model has now been developed and the CCG began the procurement process in May 2011. Service users and carers were involved in developing specifications for the services and the tender evaluation panel will include service users and carers, with new services operational in April.

PATIENT AND PUBLIC INVOLVEMENT The CCG understands that patient experience, engagement and involvement are pivotal to its commissioning strategy and decision-making, so is proactively working to further develop an already-established range of sustainable engagement mechanisms to ensure that patient feedback is captured and fed into the commissioning cycle at all stages.

A citizens’ health panel of more than 3,000 individual and group members has already been established with a membership that reflects the diversity of the local population. The group regularly completes questionnaires and opinion surveys and feeds into local and national consultations.

More than half of Nottingham’s GP practices have patient participation groups (PPGs) that meet regularly to feedback on care provided at practice level and influence future service provision, and more practices are being encouraged to establish PPGs in the coming months. Each clinical locality also has patient representation on its board.

The patient experience group meets regularly to discuss developments in local NHS commissioning. Recruitment is ongoing to encourage representatives from all provider organisations and GP practice PPGs.

A patient engagement toolkit for commissioners and supporting training programme have been produced and rolled out across the organisation to ensure that commissioners are involving patients throughout the commissioning cycle and have an opportunity at the earliest stage to feed into proposals for service development and redesign. The toolkit includes a stepby-step interactive resource to guide commissioners through the engagement process, providing them with all the necessary tools. There has been a shift in emphasis in recent months to ensure that patient opinion is not just captured and used but that the CCG can evidence where patient involvement has had a direct impact on commissioning decisions. The annual Real Accountability Report summarises how patients were engaged and what the outcomes were. All engagement activity relating to commissioning decisions is reported on and available to view on the CCG website.

NHS Nottingham City CCG has taken great strides forward since April 2011, establishing itself as a sustainable, effective and dynamic organisation committed to working with its patients and partners to achieve better health outcomes for the population of Nottingham City. It is already working closely with stakeholders and delivering improved quality, innovative interventions, efficiency savings and increased patient satisfaction. With delegated commissioning responsibility from one of the country’s top 10 PCTs (World-Class Commissioning), the CCG is aiming high and intends to be a trail-blazer in clinical commissioning success.

For further information about NHS Nottingham City CCG, contact Sarah Hewitt, head of commissioning development on 0115 912 3384 or email sarah.hewitt@nottinghamcity.nhs.uk.

SPONSORED FEATURE MALNUTRITION

EXPOSED

The Missed Opportunity of Managing Malnutrition

SHAILEN RAO, MD SOAR BEYOND LTD SERVICE PROVIDER OF MEDICINES MANAGEMENT SERVICES TO PCTS AND CCGS.

What if I told you that there has been a much maligned or ignored area of health in primary and acute care that could deliver all of the following?

• 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 Now what if I told you that you can actually see results and reduce costs in a very short time frame - months, in fact, not years? And that NICE recognises it as No. 3 of all of the NICE clinical guidelines that it has produced for delivering substantial cost savings?5 As Commissioners or Clinicians working in the new outcomedriven NHS, I should most certainly have your attention, and quite probably your disbelief. It may sound too good to be true but the facts are clear and simple yet malnutrition seems to have been a well-guarded secret.

Treating malnutrition with oral nutritional supplements leads to health benefits such as reduced mortality, fewer complications including infections & pressure ulcers, functional benefits and weight gain.6 Therefore, management of malnutrition can actually help you deliver on the following commissioning priorities: • NHS Outcomes Framework • • • • •

QIPP- Quality, Innovation, Productivity and Prevention Care Closer to Home Care of the Elderly Reducing Re-admission Rates Productivity savings- of £28,472 per 100,000 population7

14 | MAR/APR 2012

SO, WHAT IS MALNUTRITION AND WHO IS AT RISK IN THE UK? Malnutrition is a state of nutrition in which a deficiency, excess or imbalance of energy, protein and other nutrients causes measurable adverse effects on tissue, body form (body shape, size and composition), function and clinical outcome8. Malnutrition effectively refers to under-nutrition.

Disease related malnutrition costs in excess of £13billion per annum, based on malnutrition prevalence figures and the associated costs of both health & social care.9 NICE recommends screening for malnutrition in all settings using the validated MUST screening tool; a simple and quick means to identify rapid weight loss and loss of appetite. See http://www. bapen.org.uk/must-calculator.html High risk groups of patients include: • People with COPD • Elderly and people with dementia • People with cancer • People recovering from surgery • People with pressure ulcers • People who cannot swallow Undoubtedly all of these patients will feature in your list of local priorities, but are your healthcare professionals taking MUST scores and treating patients with Oral Nutritional Supplements (ONS) where appropriate?

A study conducted in Peterborough showed that implementation of a screening programme increased use of care plans, reduced hospital admissions by 31% and length of hospital stay by 58%.10 WHY IS IT MISUNDERSTOOD? ONS is an area that has been subjected to blanket ”bans” on prescribing in some areas, targeted by Medicines Management as a “quick win” or in other cases requiring the intervention of a dietician (when we know that dietetics is vastly under-resourced in the community), therefore preventing the patients that could benefit from supplementation from receiving treatment.

SPONSORED FEATURE MALNUTRITION

There is a perception of high wastage of these products; a perception that is often validated when GPs and District Nurses turn up at a patient’s house to find cupboards full of supplements. Whilst this may be true in some cases, this may have tainted the views of the overall value of treatment with ONS amongst prescribers and medicines management teams alike.

A lack of understanding of the evidence base may have led to ONS being considered “expensive” in an NHS focussed on reducing the prescribing budget rather than improving overall outcomes and therefore healthcare costs. In fact, prescribable nutritional support only amounts to less than 2% of the healthcare costs on malnutrition- the other 98% is on hospital care, long-term care facilities and GP visits- much of this cost is avoidable. 11

PRACTICAL STRATEGIES Below are some recommended practical strategies to support screening & treatment of malnutrition: •

• •

•

Educate & up-skill a range of healthcare professional e.g.

GPs, practice nurses, district nurses, pharmacists to identify malnutrition and manage malnutrition Implement MUST screening and scores within primary and secondary care settings Initiate review programmes to ensure appropriate use of oral nutrition supplements (including initiation, adherence, exit strategies and stopping rates to minimise wastage) Develop malnutrition pathways and prescribing guidance for GPs, who often find this a confusing area, in the community

WHAT NEEDS TO BE DONE? Finding and treating undetected malnutrition quickly and effectively is a “no-brainer” investment and one that the NHS cannot afford to ignore. To make it happen it will need just the kind of thinking and action that will be required if clinical commissioning is to be successful and turning this into a reality.

Here’s what Dr Mike Walton, Commissioning GP, St Albans had to say about the subject: “Prescribers and commissioners need to be made aware of the hidden human, fiscal and clinical costs of malnutrition. The covert risk of malnutrition and its complications is very real in the UK. There is valid evidence supporting oral nutritional supplementation (ONS) in a variety of clinical situations which can lead to improved patient outcomes and quality of life. The broad-brush labelling of ONS as a ‘bad thing’ and unaffordable in the NHS will lead to at-risk people being deprived of effective health care. The financial drain on the NHS of NOT treating malnutrition appropriately will add financial burden on NHS funders and deny patients of medical care.

There is a need for NHS commissioners and medicines management teams to have a sensible discussion about screening for and properly treating malnutrition. “ This article was supported by an unrestricted educational grant

by Nutricia Ltd.

REFERENCES: 1. Stratton RJ et al. Clin Nutr Supplements 2011;6(1):16. 8. Cawood AL et al. Clin Nutr Supplements 2010;5:123. Cawood AL et al. Clin Nutr Supplements 2010;5:123.

2. Stratton RJ et al. Age Res Rev 2005;4(3):422-450.

3. Cawood AL et al. Proceedings of the Nutrition Society 2010; 69 OCE7, E544 4. http://www.nice.org.uk/usingguidance/benefitsofimplementation/costsavingguidance.jsp 5. Stratton RJ and Elia, M (2007). A review of reviews: A new look at the evidence for oral nutritional supplements in clinical practice ( Clin Nutr ( supplement 1) 2:5- 23.

6. National Institute for Clinical Excellence (NICE) 2006; Clinical Guidance 32 7. Elia M. (Chair & Eds.), The MUST Report. Development and use of the ‘Malnutrition Universal Screening Tool’ (‘MUST’) for adults. A report by the Malnutrition Advisory Group of the British Association for Parenteral and Enteral Nutrition, (BAPEN, 2003).

8. Elia M and Russell CA. Combating Malnutrition: Recommendations for Action. Report from the Advisory Group on malnutrition, led by BAPEN. 2009 9. Cawood AL, Smith A, Pickles S, Church S, Dalrymple-Smith J, Elia M et al. Effectiveness of implementing ‘MUST’ into care homes within Peterborough Primary Care Trust, England. Clinical Nutrition (Supplements) 2009; 4(2):81.

10. Elia M et al. The cost of disease-related malnutrition in the UK in 2007 (public expenditure only) in Combating Malnutrition; Recommendations for Action. Report from the advisory group on malnutrition, led by BAPEN. 2009

MAR/APR 2012 | 15

IN ACTION INTERVIEW

When worlds align As negativity towards the Health and Social Care Bill runs rife in the media, advocates of clinical commissioning cannot seem to shout loud enough. JULIA DENNISON meets DR ANN BOWMAN, chair of Greater Preston CCG and manager LOUISE GILES to find out why they’re so positive about the future

W CCG Greater Preston PATIENT POPULATION 217,000 PRACTICES IN GROUP 35 BOARD MEMBERS Six GPs CHAIR Dr Ann Bowman MANAGER Louise Giles

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hen I arrive at NHS Central Lancashire, now sharing its headquarters with three clinical commissioning groups, it’s a hive of activity. There is little evidence of this PCT downsizing we have been hearing about. In fact, everyone is positive and pitching in. The reality is, apart from a few people choosing voluntary redundancy, many of the people working for this PCT have jobs in commissioning.

Louise Giles is one such staff member who now works as lead manager across Greater Preston CCG, and Chorley and South Ribble CCG, which call Jubilee House in Leyland their administrative home, along with West Lancashire CCG. When I meet

with her and Dr Ann Bowman, who is chair of Greater Preston CCG, they admit they are wary of turning on the TV, with all the negativity that has ensued around Health Secretary Andrew Lansley’s plans for the NHS, for these healthcare professionals are what seems to be a rarity of late: advocates of clinical commissioning.

Dr Bowman has been a GP for 25 years and involved in commissioning in all its various forms. “In the previous [commissioning] incarnation, we were in a different PCT to this, and so when the changes came along it was an opportunity for us to move back into alignment with Preston, which is what we’d always wanted as a practice,” she explains. Because she had been working with a different PCT, she hadn’t thought of putting herself forward for

IN ACTION INTERVIEW

election when the local medical committee called for it (the LMC lead the election of CCG leads). She was encouraged by colleagues to stand for chair and decided to go for it. “I’d always been very enthusiastic about the whole commissioning idea,” she says. “I’ve always said that clinicians need to be involved in commissioning and that was the only way that it would be successful. So I was very enthusiastic about the reforms from the start.”

BACKGROUNDS IN COMMISSIONING Dr Bowman is a GP at Berry Lane Medical Practice, which sits on the border between NHS Central Lancashire and NHS East Lancashire. She started out trying to juggle her practice partnership with her role as CCG chair, but because the chairship

requires five sessions a week, it soon became impossible. So she renounced her partnership and became a salaried GP for two sessions a week to free up her time. “There [is] a strong feeling from the GP membership that you need to keep a foothold in general practice so that you keep that contact [with patients],” she explains of why she still works at the practice. Berry Lane has been very supportive, considering the last time it had a change in partner was 20 years ago.

Where Dr Bowman keeps her roots in general practice, Giles’s background is working for the PCT. A registered nurse, she came into commissioning three years ago, initially focusing on long-term conditions and urgent care. She was then asked to support the two CCGs working out of Jubilee House last April. Even

MAR/APR 2012 | 17

IN ACTION INTERVIEW

before the white paper came along, NHS Central Lancashire had gone through a restructure, so change is nothing new to Giles and her colleagues. “It’s just about how we adapt and we’ve had to change our thinking,” she says. “There are still some people in the PCT still doing their old roles, but we’re now aligning ourselves with being a commissioning support service to support the CCGs.” This has involved assigning PCT staff members to various roles within the CCGs to work towards a better idea of what the staff structure will look like under commissioning – whether that means working for the National Commissioning Board, a CCG or within the commissioning support service. “There’s a lot of uncertainty – people applying for voluntary redundancy and we have got some temporary staff in – but we are trying to work and cover lots of roles,” says Giles.

“It’s almost as if we’ve got two [tasks] – closing down the PCT and having to evolve into new organisations.” The added difficulty for NHS Central Lancashire is that it covers three different CCGs, so the staff will be divvied up between them, to which Giles adds: “From our perspective, it’s: How do you cut things in three ways for three different CCGs?” For Dr Bowman, it’s about working with Chorley and South Ribble and West Lancashire CCGs for the best outcomes.

“We have a single provider between us, really – the local trust. We’re, by a very big margin, their main customers, and so we know we have to work very closely with them,” she says. She plans to share senior members of staff – like the accountable officer and chief finance officer – with Chorley and South Ribble, while local teams will look after service redesign and

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GP engagement. “We’re hoping that way we can keep the membership feeling that there’s a local organisation for them, but we can get the economies of scale that we need to do to make the management allowance work for us,” Dr Bowman explains.

“What we don’t want is for the provider organisations to split us and take advantage; we know we have to work very closely together to make that effective.”

“If clinicians don’t do it, how

does it connect up? How do you connect up what we hear every day in our surgeries and what patients say it is we want? I think we’re very close to that as clinicians. It gives you a perspective on things that I don’t think you’d ever have if you didn’t hear those patient stories” The executive board at Greater Preston CCG decided from the outset to have as lean a structure as possible in order to make the management allowance of £25 a patient head go further – on the basis that it is easier to add things on than to take them off. “What will be really crucial is trying to work that structure through these next 12 months,” says Dr Bowman. “So we’ve got the shadow year to operate that structure and see how it feels and see how it links into the commissioning support organisation. I think that’s going to be key in informing us as a CCG as to whether

we’ve got that structure right or is it too lean, not lean enough or do we have the right kind of roles or not? That’s going to be a key part of the next year for us.” The uncertainties continue around whether things like continuing healthcare will be with the NCB or the CCGs. “What we’ve tried to do is leave a contingency [plan], because there are so many unknowns that we potentially may not have costed for,” says Giles.

ALL PUBLICITY’S NOT GOOD PUBLICITY Giles and Dr Bowman believe the negative publicity around the Health and Social Care Bill has hampered the CCG’s progress.

“There’s clearly a huge amount of anxiety and concern, which his being fuelled by all this news,” says Dr Bowman. “From where we’re sitting, it seems very hard to get out any positive messages. Similarly with the GPs, we’re trying to help them to see that we think we are doing some things that they want to have happen so that they can see a more positive side of it. But it’s very difficult.” She remains certain that clinically-led commissioning is the way forward. “If clinicians don’t do it, how does it connect up? How do you connect up what we hear every day in our surgeries and what patients say it is we want? I think we’re very close to that as clinicians. It gives you a perspective on things that I don’t think you’d ever have if you didn’t hear those patient stories.”

Dr Bowman also believes being a clinician gives you an idea of what services are working for patients and what aren’t; which need more resource and which could be cut back: “There’s an immediacy connecting it to what the patients actually need and I don’t think you get it any other

IN ACTION INTERVIEW

way.” Giles believes having those dialogues with consultants in secondary care helps develop better patient pathways. Greater Preston CCG currently has only six GP board members and as yet doesn’t have any nurse or secondary care representatives.

Department of Health guidance says these members of the governing body must not have any conflict of interest in relation to the CCG’s responsibilities. This will usually mean that a doctor or nurse working in a provider with which a CCG has a contractual relationship would not be able to sit on the governing body. However, this can prove a challenge. “It’s difficult to see how you’re going to get a consultant who doesn’t have a conflict of interest,” admits Dr Bowman. “If you think we send patients to Manchester, Blackburn, and Liverpool – how far afield are you going to have to go before you find someone who doesn’t have a conflict of interest?”

Another benefit to GPs leading the way, for Giles and Dr Bowman, is that patient pathways are considered first, before finances. As a result of this approach,

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services explored by Greater Preston CCG include a focus on medicines management, resulting in significant prescribing savings this year. By changing the culture around medicines management and improving its image in practices, surgeries now ask for the service instead of begrudging it.

WORKING TOGETHER FOR A BETTER OUTCOME Integrated care is another important area for Greater Preston CCG. “There’s been a lot of silo working nationally – so social services, public health, primary care, secondary care, and community care – and a lot of those roles are not as closely aligned as they need to be,” says Dr Bowman. “If we’re going to meet the Nicholson challenge and save that money, the only way that’s going to work is by us all working together in a way that hasn’t happened until now and I see that as my big job, really.” She believes a major downsize of secondary care needs to happen to save that money, shifting the funds it releases into the community. She would also like to see more of an emphasis on promoting health in the population,

for which cooperation with public health and local authorities will be necessary.

With both the CCGs she works with, Giles and her colleagues ensure there are quality outcomes built into the contracts.

Furthermore, a conflict of interest policy ensures commissioners don’t favour themselves as providers.

As I leave, the CCGs are little over a month away from shadow form and the health bill is still being debated in Parliament. Dr Bowman is convinced Lansley’s original vision – putting the GPs at the front of commissioning healthcare – will remain intact. “I could see things going wrong, but I had no voice or system to allow me to say to the providers: ‘This is not okay’,” she explains. “Now I think there is.” What’s more is the providers have been only too ready to improve. “They know things aren’t right sometimes as well, but they didn’t necessarily have a way to address that either. So we can support them by going back to their managers and say: ‘Look, we’ve figured out a way we can do this better.’”

COMMUNITY CARE COMMENT

The right stuff The NHS Right Care programme is focused on increasing value for patients and commissioners by targeting areas of healthcare like population, clinical networks, and shared decision-making. As warm and fuzzy as it sounds, it could just save the NHS. JULIAN PATTERSON director of communications of Primary Care Commissioning, explains why

D

avid Colin-Thomé believes that if the NHS takes Right Care to heart “you really could have a sustainable health service with the resources we have today”. It’s a bold claim, but not a rash one.

NHS Right Care is based on reducing unnecessary clinical interventions and eliminating needless variation in health investment. If it works, patients and taxpayers will share the benefits. In economic terms that could amount to billions of pounds of recurrent savings.

Right Care will also mean that more care is delivered out of hospital. This also has profound economic consequences.

Colin-Thomé says: “The NHS spends around £6bn on outpatient services. About twothirds of the 60 million contacts are follow-up appointments and in a similar proportion of cases the patient is already seeing their GP. How many of these people really need to be seen in hospital?”

No wonder the architects of the QIPP programme are so keen.

Colin-Thomé, a former GP and retired clinical director with the Department of Health, joined the Right Care team at the invitation of the eminent clinician and NHS chief knowledge officer Sir Muir Gray who leads the workstream.

He believes that Right Care needs to be more than the hobbyhorse of a few clinicians. “It needs to be systematic and widespread, part of the day-to-day business of commissioners as well as clinicians,” he says.

It also needs to be discriminating.

“The QIPP programme really isn’t an arbitrary cuts programme,” says Colin-Thomé, but he acknowledges that managers under orders to save money may resort to “crude rationing and salami-slicing budgets”.

“The health service isn’t strong on discernment,” he says, “but a clinically directed commissioning system should be different. The idea that better care is more expensive is wrong. The best possible care for patients is also usually the most cost- effective.”

The Right Care team is responsible for the NHS Atlas of Variation, which maps levels of health investment by clinical condition across the NHS in England.

Right Care is not against variation per se, but the needless variation that arises from the lack of a coherent strategy and from differences in data quality, analytical skill, commissioning expertise, clinical input, management ability and political will.

The Atlas of Variation is one of several useful knowledge management tools for commissioners, but Colin-Thomé does not want to exaggerate its importance: “It’s a good start, not magic. We can provide the information for better management, but responsibility for taking the decisions has to lie with clinicians and managers.”

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COMMUNITY CARE COMMENT

MAR/APR 2012 | 23

COMMUNITY CARE COMMENT

Prescribing is well regulated.

Commissioners and clinicians can refer to NICE guidelines for decisions about the drugs they make available. Elective surgery is the Wild West by comparison where clinical judgement fights it out with clinical preference and clinical prejudice.

The Liverpool-based cardiologist Mike Chester has campaigned for more than a decade for more discriminating use of angioplasty and stent. In a paper published last year, Dr Chester noted that the biggest study to date concluded that “planned angioplasty produced only a relatively small and temporary improvement and was not cost effective”. He estimated the cost to the taxpayer of the 50,000 unnecessary procedures performed over the past 13 years at more than £250m.

He went on to say that if stent were a drug it would have been banned.

Similar criticism can be levelled against other procedures including cataract operations, hysterectomy, gall bladder removal and prostatectomy.

Around 18% of knee replacement operations have been shown to produce no clinical benefit – these statistics were obtained from patients, not doctors. Knee replacement costs on average £5,800. There is a four-fold variation in expenditure between PCTs and the annual saving if those above the median reduced their spending to average levels would be £39m.

Colin-Thomé says: “A procedure is introduced for a good reason, but over time the reasons for using it start to drift, the thresholds for using the procedure are lowered and the inevitable result is that people who may not need it have it anyway.”

The consequences of “clinical drift” are not only financial. Unnecessary procedures may have negative consequences for patients’ quality of life and their health.

This is why the elimination of “low value” interventions features prominently in the Right Care programme.

Mike Chester believes the health benefits start in the consulting room. “The best intervention is to spend an hour with the patient, give them a cup of tea and explain that angina does not damage the heart. It is like botox – the worry lines disappear.

“There are huge savings from this single intervention. Heart attacks fall because people see it is worth taking exercise and taking asprin because they are not going to die after all.

“Business had it right: it is all about the customer experience: if you look after that, the spreadsheet will look after itself. Patients are not stupid: they are frightened and ignorant and if you change that then they will engage with you in a sensible discussion about the right pathway.”

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The words matter. Talk of “low value interventions” does little to engage clinicians. Value and cost will be easily confused by patients and the media.

The headline opportunities are obvious: “Patients denied routine operations as NHS cuts deepen”.

This is one reason why in a report commissioned by Sir Bruce Keogh, the Right Care team recommended “value based” and “effective clinical commissioning” as alternatives to the current language about “procedures of limited clinical value”.

The other vital ingredient in Right Care is that patients are properly involved in decisions about the care they receive. All the evidence is that when they understand the options available to them including the possible implications of a procedure, some patients choose not to have surgery.

Numerous studies including several in the UK have shown that where decision support tools are used by doctors and patients, there are fewer surgical interventions. A central principle of Right Care is that the evidence must come from the patient.

As Colin-Thomé puts it: “Only the patient can say if the care had been right for them. Nobody else, including the clinician, is qualified to make that call. The key question to ask about an intervention is ‘Has it made a difference to the patient?’

The answer forms part of the evidence you present to subsequent patients to help them decide on the right care for them.”

“The best intervention is

to spend an hour with the patient, give them a cup of tea and explain that angina does not damage the heart.

It is like botox – the worry lines disappear”

COMMUNITY CARE COMMENT

INFORMATION TECHNOLOGY DATA MANAGEMENT

Data dilemma

CARRIE SERVICE takes a look at the ins and outs of data management; how it can make or break commissioning and how CCGs should go about tackling it

G

ood data management is pivotal to the running of any practice and is even more so in the running of a successful clinical commissioning group.

Many GPs are now having to become more aware of the process involved in data management in the lead up to clinical commissioning, particularly as information governance has been highlighted as a “necessary qualification” for the authorisation of CCGs by chief executive of the NHS, Sir David Nicholson.

INFORMATION OVERLOAD The National Information Governance Board for Health and Social Care (NIGB) outlines the following possible outcomes from not getting to grips with data management or “serious failures in information governance” as they put it: n Damage and distress to patients and service users through the inappropriate disclosure or use of their personal and

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confidential information and thereby harming public trust in the NHS. n Investigation and enforcement action by the Information Commissioner’s Office for breaching data protection requirements, including the imposition of monetary penalties up to £500,000. n Complaints and legal proceedings for breach of confidence and unjustified interference with privacy both against the organisation and individual staff members.

These outcomes emphasise the extent to which data management really needs to be prioritised in order for CCGs to be fully prepared in time for April 2013. Research carried out last year by law firm DMH Stallard showed that 72% of GPs felt they had no expertise in the “business” element of running a CCG and admitted having no experience in areas such as data management, costing clinical services, negotiating with providers, procurement law and contract and financial management. It is clear this will be unknown territory for many GPs, so

INFORMATION TECHNOLOGY DATA MANAGEMENT

patient care and it should be noted that it is the first step in a long process to improve services, says Ben Skinner, head of library and knowledge services at the Royal Sussex County Hospital library: “I do not believe it is possible or desirable to improve the quality and cost-effectiveness of health services by focusing on data alone. Data interpretation can describe how services have been performing, tell us which pathways are working well and not so well, and give us targets to aim for, but it does not tell us how to get where we want to be.” Skinner suggests that if CCGs do not know how to interpret patient data, no matter how well it is managed extracted or collected, it will not provide the key to a successful CCG.

“The best way to tackle

the problem of data management is to embrace it as an integral part of the commissioning process”

it is important that the right systems and management staff are in place to ensure ease of access and management of data. The NGIB, in its guidance document, emphasises the important role that Caldicott Guardians and senior information risk-owners play in maintaining information governance throughout the transition from PCTs to CCGs. Dame Fiona Caldicott, the originator of Caldicott Guardians, highlighted the difficult nature of data management, saying: “It has become clear that there is sometimes a lack of understanding about the rules and this can act as a barrier to exchanging information that would benefit the patient.

On other occasions, this has resulted in too much information being disclosed.” Health Secretary Andrew Lansley also called it a “complex issue”, so it is clear that it will be a learning curve for all.

Stoke-on-Trent PCT has already implemented software to improve information management and extraction across 45 of its practices. Neil Ryder, data quality manager at NHS Stoke-on-Trent,

uses the software to produce data reports from his desktop computer, meaning that the data quality team no longer has to collate the data from various practices as it did previously. “I would estimate that it has saved our data collection time across the PCT by about 90%,” he says, which is a significant figure and something for emerging CCGs to take into consideration in the transition period. Deploying a system that is efficient is vital so that data managers can “create clear analysis and reports that enable commissioners to make decisions about the quality and cost of care,” says Matt Murphy from software provider Emis. “Clinical commissioning groups have time and resource constraints, and they tell us that they want meaningful and intelligent data that can be understood and acted upon promptly.”

OPEN TO INTERPRETATION Although data management could make or break a CCG, good data management does not equate to a golden ticket to improved

In order to carry out effective commissioning, there needs to be an examination of all information available. In Skinner’s experience, most commissioners do not make use of appropriate expertise when sourcing evidence: “Just as information analysts are employed to help commissioning groups make sense of the data, library and knowledge service teams must be employed to make sense of the evidence and to promote the sharing of knowledge.” Katherine Cheema, specialist information analyst at the Quality Observatory for NHS South East Coast agrees: “Whilst such high level reporting is naturally very useful, in our experience CCGs require more personalised, local information expertise to ensure that they are able to interpret the data they are provided and use it appropriately.”

TEAM TACTICS The best way to tackle data management is to embrace it as part of commissioning and keep data handling in-house if possible.

Cheema comments: “Expertise allied to specific CCGs will not only be able to focus on CCG priorities, but will also get to know the CCGs patients’ needs and the clinicians’ preferences to ensure that bespoke, high quality and timely analysis is delivered. Different approaches in two CCGs have demonstrated this very well; where one CCG has embraced the analyst as ‘part of the team’ they have benefitted greatly not only in terms of the provision of and support for high quality analysis and tools, but in terms of productivity.”

MAR/APR 2012 | 27

INFORMATION TECHNOLOGY TOP TIPS

SEVEN STEPS FOR SUCCESSFUL DATA MINING Commissioning and IT expert, DR SHANE GORDON, gives his advice for analysing data

1 3

6

SET OUT YOUR AGENDA BEFORE YOU GET STARTED You need to clarify why you are doing it. Is it to demonstrate commissioning intentions, redesign services or is it for a business case? The biggest pitfall is getting lost in all the data you accumulate. Without a clear goal you risk becoming confused and not completing the task.

CONSIDER WHAT POPULATION YOU’RE INTERESTED IN Your population data must be relevant to your question. Factors to consider include geography, age, medical conditions, routes of presentation, and time period. Questions to ask include: What was the highest-cost route of admission? What was the highest-cost specialty for that route? What was the highest-cost diagnosis in that specialty? Other important factors to consider are benchmarking; morbidity and mortality; incidence and prevalence; demographics; activity and cost; waiting times; public health; staff costs and patient data. Make yourself aware of trends and changes in coding. The most common one to be aware of is the change from Finished Consultant Episode to Spells in 2006 – this resulted in significant increases in the number of items appearing in the hospital data (SUS data).

SUS DATA IS THE COMMISSIONING GOLDEN EGG SUS data is a rich source of information for practice-based commissioners because it shows how patients reach hospital and what happens to them after they are admitted. PCTs have SUS data – but you have to rely on them to give it to you.

There are various third party resources for SUS data – for instance, Dr Foster and Sollis – but you have to pay for it.

My PBC consortium purchased a tool to access SUS data and the licence covered an unlimited number of users. This cost 10p per patient in the consortium per year.

With the exception of SUS data, all are in the public domain or on NHSNet, and you don’t need to go through your PCT to get them.

2 4 5 7

DECIDE WHO YOUR AUDIENCE IS Who you are collecting the data for: CCG colleagues, your PCT, or your own practice? A finance director will be less interested in the finer points of disease prevalence and much more interested in bigger financial issues such as risk, while colleagues will want to know more about the clinical aspects.

FRAME YOUR QUESTION When you frame the question you need to consider if it is top-down or bottom-up.

For example: “What’s the biggest cause of admission to hospital for my cluster?” is different from: “How many patients could benefit from falls prevention services?”

Again, think about your outcomes and audience when deciding your approach.

BREAK THE QUESTION DOWN INTO SUB-QUESTIONS If the question you are asking is complex you may need to break it down. You should also consider whether you need complete data or whether a snapshot or subset will illustrate the case in sufficient depth.

DECIDE WHAT DATA IS RELEVANT Once you start to become clear about the outcome you want, consider the scope of the data you should collect – national or local? Sometimes this will depend on the type of data you need or what is available.

Data is vital for your business planning and I would advise you develop someone in your organisation who specialises in it. Without competency in handling data, you will find it very difficult to make your case for commissioning or providing services. It might be perceived as nerdy, but data can effect real change.

Dr Shane Gordon is a GP in Tiptree, Essex. This article first appeared on an NHS Alliance commissioning resource site

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MANAGING COMMISSIONING SUPPORT

Commissioning conundrum CARRIE SERVICE takes a look at the array of support available to emerging CCGs and how they can best prepare for the coming months

W

ith the commencement of CCGs on the horizon, it can seem as though there is a plethora of information and support being offered all at once to help PCTs and GPs with the transition.

How much of this is actually useful and how much is simply an opportunity for companies to take advantage of an emerging market is debatable. But one thing’s clear, both will need help and a clear strategy in order to tackle the transition effectively.

A CHANGE OF ROLE Understanding that many roles (and that may include your own) will be evolving

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to cater to new demands, is fundamental to building an efficient commissioning team. Kasmin Cooney OBE, is MD of Righttrack, a learning and development consultancy that offers training to CCGs and GP practices. She believes not only will people’s roles be changing but the relationships between those roles will change too: “All GPs will have to think more about the overall impact of their decision-making on their CCG. Members of a CCG will be coming together as separate individuals and will very quickly need to be working as effective teams.”

This could prove problematic for GPs who have not been used to overseeing such a wide range of individuals and issues. A possible solution to this could be to provide

MANAGING COMMISSIONING SUPPORT

management training to widen the skills set of those with a more clinically based background. However, Cooney doesn’t believe this should be done en masse and may not suit every CCG, due to the varying levels of experience and skills GPs bring with them: “Management training must be tailored to take account of the level of expertise of individual GPs in the CCG, rather than adopting a centralised one-sizefits-all approach.” Training can also be used as a team-building exercise, adds Cooney: “It would be better to train the CCG management group together, to ensure that they operate as a cohesive team rather than a collection of individuals with different agendas.”

SEE THINGS CLEARLY Mike Singer, director of Civica Health & Social Care, which calculates plans for nearly 200 commissioning bodies and service providers, believes that the media hype around the health bill has created a distorted message about what GPs, CCGs and CSUs (clinical support units) actually need to be concerned about. He proposes that all of the issues concerned with commissioning can be split into two groups: “the transformational and the transactional. The latter is assuming ever greater importance as GP groups become the key recipients of funding,” he explains.

“Transformation is the current headlinemaker… However, the oft-forgotten transactional side is equally crucial: How can the commissioning process be established by GPs in a way that budgets can be monitored and managed?”

Data management is one pressing issue that CCGs will have to confront in order answer this, as it will play a vital part in decisions around procuring services and management of the treatment of illnesses (see p30). This should be sooner rather than later too as changes to how reporting is carried out could throw another spanner in the works. “The challenge for GPs is whether they will have the information to hand quickly enough to make the decisions,” says Singer. “CCGs/GP groups already vary considerably in size, but the common factor is they will be handling greatly increased levels of data and will need to allocate as funding and reporting moves away from annual funding rounds towards service line reporting.”

WHO TO CONSULT? It’s all very well saying PCTs need to adapt in order to ease the transfer to CCGs, but in some cases, especially where there are redundancies being made, there simply isn’t the capacity or the provision to do it alone.

Commissioning support services (or CSSs as they are also known) have been named

as the solution to this problem. Choosing the right support, however, will require a little work: “GP groups need to be certain that new suppliers in particular can deliver the granularity of information needed,” says Singer. The best way to do this is to keep track of suppliers that have the right experience: “GP groups will certainly need to speak to suppliers that have a track record in understanding – and streamlining – areas such as service commissioning and claims reconciliations processes as well as for overall financial reporting.

The most forward-looking practitioner groups will already have management information systems that are already feeding information back to commissioners and providers. ”

“Members of a CCG will be

coming together as separate individuals and will very quickly need to be working as effective teams” DO YOUR RESEARCH There is additional help available for emerging CCGs in the form of companies such as HSP (Health Solutions Partnership), which provides a range of information and advice on its website, including case studies and publications, live news streams, and forums and articles about commissioning.

Nuffield Trust also provides resources on commissioning, as does the Commissioning Support Programme, including free online training in its ‘commissioner’s kitbag’.

For a more topic-specific guide to commissioning, NICE offers web-based commissioning guides comprised of a series of text-based web pages that provide categorised information on the main clinical and service-related issues involved in commissioning. Each guide contains a commissioning and benchmarking tool that can be used to estimate the level of services needed in the local area and also the cost of local commissioning decisions. The guides provide information for staff right across the commissioning team and they list the following people as their intended readership: commissioning staff within PCTs, GP pathfinder organisations and GP consortia as they emerge, local authority commissioners, business and programme managers and finance and information staff.

The key is to remember that your PCT already has a wide range of knowledge on commissioning; it has, after all, been its job all along. So be sure to utilise these skills while at the same time ensuring those who are in new territory are as informed as they can be.

For a free six month subscription to Commissioning Success: your bi-monthly guide to commissioning, simply email subscriptions@intelligentmedia.co.uk with your name address and contact details.

For daily updates and news visit www.commissioningsuccess.com

MAR/APR 2012 | 31

MANAGING COMMISSIONING LEGAL

Buyer beware?

In a look at GP commissioning and procurement, lawyers OLIVER POOL and DAVID HANSOM examine some of the unintended consequences – and pitfalls – lurking in the new work of CCGs

M

ost GPs involved in commissioning will have been aware for some time that getting their hands on the wheel hasn’t given them the powers to award services entirely as they please. They are dealing with public money and so are covered by the EU Directives on Public Procurement, or ‘competition law’, as it has become colloquially known in healthcare circles. The Public Contracts Regulations 2006 are the rules which are designed to ensure that contracts are awarded properly, transparently, and openly.

The Regulations apply to all contracts awarded by a CCG, and the rules become more detailed and onerous depending on the value of contract awarded. So, broadly, an any-willing-provider contract that is expected to deliver only a small amount of activity will be subject to the least stringent criteria, whereas a block contract for a large and guaranteed amount of work will be much more tightly controlled requiring in some cases full EU wide advertisement.

In other sectors, those buying services are constrained by particularly rigid rules relating to timescales and precise hoops through which an organisation must jump. It will be a relief to GP commissioners to know that most healthcare services are what is known as ‘part B’ services, and so a lesser regime applies. For instance, there is generally no need for a notice to be advertised EU-wide through the Official Journal of the EU (often called an ‘OJEU notice’) before commissioning a service – although the opportunity to bid for work still has to be fairly advertised and a transparent process to select the winning bidders has to be implemented Rather than go through a new procurement process each time a service is required, commissioners will often go through a single initial procurement to set up a ‘framework’ – a list of ‘pre-approved’ providers that they can quickly call off services from as required. Frameworks are generally for a maximum duration of four years and do not give any guaranteed levels of work to the contractors appointed.

The rules are complicated, because many of the “gaps” in the law are filled by EU case law, and so even those in the public sector with long experience of the Regulations fall foul of them on occasions.

In the worst case scenario, a procurement that is flawed can lead to the contract being cancelled altogether after award. Again, GP

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commissioners will be relieved to know that, broadly, this does not apply to part B, healthcare services. But the point remains that if mistakes in the procurement are discovered by a disgruntled losing bidder, damages can be awarded against the CCG, and fines imposed.

It seems likely that the healthcare market will become increasingly competitive over time, and this increases the risk of those who have not been awarded work or contracts challenging a procurement. The current difficult economic climate is already leading to many more procurement challenges as bidders fight for every opportunity.

These risks are real, and In other sectors, those such challenges already happen regularly in buying services are other sectors. constrained by rigid The wider risk, of course, is that rules. It will be a relief to some of the central commissioners to know that Government policy most healthcare services are in health does not sit comfortably with known as ‘part B’ services, the rigour of the so a lesser regime applies” EU procurement rules. We are already seeing challenges and complaints about the creation of new social enterprises and mutuals to deliver various types of social care in place of the PCT role. An example of this is in Gloucestershire, where the PCT decided to set up a new social enterprise to deliver its provider services and award a services contract to it directly without a procurement to see who would be the best provider. The PCT has been challenged under judicial review by a service user on various grounds, including the lack of compliance with procurement.

The Government has recognised this potential disjoint as a problem and, as part of the consultation undertaken by the European Commission into proposed reforms on procurement, went so far as to request from the EU a three-year exemption from the rules for new start-up social enterprises and CCGs. The request was turned down. So it is clear that these rules will apply equally to CCGs as they have done to PCTs. Procurement, then, is all about risk management. Commissioners can reduce risk by ensuring that those involved in purchasing have appropriate training on the issues and how to manage common risks and queries, together with robust base procurement documents to ensure that every competition is suitably transparent and defensible for when the inevitable challenge or complaint comes.

“

Oliver Pool and David Hansom are from Veale Wasbrough Vizards, a law firm that acts across the health sector and for GP practices, as well as for over 100 local authorities, other public bodies, and the wider public sector on public procurement law

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Locum insurance One problem, two solutions It is imperative for a practice to keep providing services and running effectively in the event of one of the GPs, practice manager or practice nurses being unable to work as a result of illness or injury.

RIChARD McEwEn explains how insurance helps

Richard McEwen is director of general business at Doctor Insurance Services*, based at 131-133 New London Road, Chelmsford, CM2 0QZ *a trading name of R.J. Hurst & Partners Ltd, authorised and regulated by the Financial Services Authority

Most practice managers will recognise the benefits of locum insurance in maintaining a service through unpredicted circumstances, providing peace of mind, but most importantly financial benefits to fund a locum practitioner in the event of incapacity to one of the key staff.

There can be a great variance in the price and terms of the covers available from locum insurance providers. Practice managers need to be certain that they are insured by a product that meets the needs of the practice and can be relied upon to pay any claims that may arise.

The premium charged for cover is important and will be one of the first points of consideration when practice managers trawl through quotes and policies.

But, locum insurance is no different to any other product; you will normally get what you pay for – where a premium looks expensive compared to other offers, there ought to be a good reason and it may worth be paying extra if it provides better cover.

Doctor Insurance Services offers two policies – Locum Platinum Plus and Locum Platinum. The former offers long-term insurability, through to age 70 if required, without the need for the insured to declare any changes in health nor any individual’s claims experience impacting on the provision of future cover. As a result, the insured could make multiple claims on their policy through the course of their working life – even if the claims related to the same condition. This provides long term insurability.

The Platinum policy is a traditional annual insurance contract providing cover on a year-by-year

basis. The upside is that the premiums are cheaper.

The downside is that the insurance is effectively underwritten at each renewal – so if there are changes in health or if claims have been made under the policy, terms are likely to be imposed. This could take the form of a premium loading, an exclusion relating to the change in health or, the worst case scenario, of future cover being declined. This would then be compounded by the fact that, given the changes in health, the staff member would have difficulties in obtaining full cover with any other insurer.

This is not to decry the cheaper Platinum model; it does of course work. Premium is a key factor and like any business, practices have budgets to meet and costs to consider. As long as the insured is aware of the terms of cover provided and accepts the long term risk, there is no issue. But, it can prove a risky strategy – you don’t particularly want to find yourself without cover in future years when a claim is more likely. It may be that an annual contract is more appropriate for some members of the team, whereas the long-game approach of Platinum Plus might suit others.

There are other factors you should consider in choosing a locum insurance provider. For example, the track record of the insurer/provider to determine their history within the market and their reliability on meeting claims. Also consider the structure of the product – specialists within the GP market will tailor their products to meet the particular requirements of GPs, usually by offering flexible deferred periods to tie in with practice agreements, or providing the ability to split cover so that the practice can mirror any locum reimbursement that may be applicable.

Cover can be provided under each contract for GPs, practice managers and practice nurses – with the product selection of Platinum or Platinum Plus to suit the individual rather than the practice. Group discounts are available on Platinum Plus and the first month of cover is free to new applications.

For further information or to discuss your requirements, please feel free to visit the website at www.doctor-locum-insurance.co.uk, call 01245 283483 or email Richard McEwen directly at richardm@robjh.co.uk

MANAGING COMMISSIONING TOP TIPS

What makes a good commissioning manager?

We offer our top five tips to commissioning management success

1

Take control

2

Know your stuff

3

Show a united front

4

Have faith in others

5

Keep your eye on the ball

It is essential that anyone involved in the management of commissioning can communicate well with and understands the needs of their team. Essential Skills for Influencing in Healthcare by Andrew Price and Andrew Scowcroft outlines the importance of being able to positively influence your staff: “What is often lacking is an approach to influencing change that has genuine integrity and trust built in from the start… It has to be demonstrated practically through the way managers and clinicians engage with their colleagues. We would advise commissioning managers not to go for a top-down approach, but to get out and talk with people on the ground, listen to the issues they raise and trust their judgement,” say the authors. This book features tips for clinicians and managers and also helpful tools to aid successful influence over staff; an essential for those who want to improve their workplace and make insightful leadership decisions.

Be sure to do your research and build a sound basis of knowledge on commissioning whether you are from a clinical or management based background. There is a wealth of useful information out there. For an up to date source of information, you’re in the right place. Our website also provides clear concise information ensuring you are on top of any new developments, while providing comment and analysis from fellow commissioners and experts in the field.

Kasmin Cooney OBE, MD of training provider Righttrack, recommends making the most of the opportunity you have to change the delivery of healthcare across your area, by encouraging shared knowledge between practices: “Local CCGs have the opportunity to set the standards of service for their communities and should ensure that best practice from individual GP surgeries can be shared amongst all practices. The new CCG structure also creates the opportunity for the sharing of costs of customer service training for non-clinical front line staff such as surgery administration and reception staff.”

Although change is upon on us, bringing with it many challenges, it is important to remember that those around you are willing and able to do their job. Remember that your PCT has a wealth of experience in commissioning services and it’s important that there is not a loss of knowledge in the transition period. Do not underestimate what other members of the team have to offer; their job description may be changing but it doesn’t mean their experience is any less valid or applicable.

Never forget what your end goal is; improving local health outcomes and providing best care for patients. ‘Transforming our healthcare system’, a paper released by the King’s Fund as a guide to commissioning outlines the following four areas that commissioners need to help drive: n A more systematic and proactive management of chronic disease n The empowerment of patients – an “untapped resource” within the NHS n A population-based approach to commissioning - directing resources to the patients with the greatest need n More integrated models of care such as integrated teams and shared budgets.

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