GPs face a seismic challenge to create systems that reward outcomes rather than activity. Kaye McIntosh asks the experts how GP commissioners can rise to the challenge.
Dr Donal Hynes, (DH) Vice chair, NHS Alliance
Dr James Kingsland, (JK) President of the National Association of Primary Care and national DH clinical commissioning lead
Ben Gowland, (BG) Chief executive Nene Commissioning
Dr Paul Charlson, (PC) Chair of Conservative Health, clinicians allied to the Conservative Party
1) What’s the scale of the challenge required in moving from commissioning activity to commissioning for patient outcomes?
DH It’s a profound change in how GPs relate to the patient and the community. The success of consortia depends on bringing the population with you – without that, any decision about services will be contested.
The real challenge will be involving the patient, so the outcome is not what we think the patient needs but what the patient says they need – if an elderly patient is falling because their partner has died, they are lonely and reaching for a drink in the evening, the answer may be more social contact, not a falls package.
JK It’s a complete change of focus. PCTs used very basic measures such as length of stay, not outcomes. They won’t admit this, but in fact Payment by Results was being used to retrospectively measure activity. A major issue for GP consortia is that commissioning for outcomes doesn’t guarantee providers a volume of work.
PC It’s a huge cultural change. We’re used to rewarding people for seeing a number of patients – not the outcomes achieved – and systems that are based on activity. The shift to a new system will need time to bed in.
Culture changes slowly and by persuasion. Making it real so that clinicians believe that the outcome measures are valid and clinically useful is a major challenge. There is the potential for gaming, as we’ve seen under Payment by Results. We need to develop effective, robust tools so people are rewarded for doing something that has clinical value.
BG It’s going to be very difficult. There’s fuzziness between the actions you take and outcomes in this complex health environment.
It will be very important to look at what the local authorities will be judged on as well as what we will be judged on and where they overlap – that becomes a real driver for change. Health and social care will have to take joint ownership of the challenge and the issues.
2) How would you define an outcome?
PC An outcome takes into account both clinical results measured in terms of mortality and morbidity and whether patients feel better as a result of treatment and the experience of being treated.
Payment for achieving optimum diabetes control or hypertension is relatively straightforward. In other areas, such as psychiatric care, it’s a little more difficult to quantify.
JK It’s not mechanistic descriptions of activity such as length of stay or admission rates. Nobody said this was going to be easy, but it’s going to be about have we improved the health of our population, reduced disease rates and increased patient satisfaction?
DH We shouldn’t be defining outcomes on our own – we have to involve the community. There has to be real communication with the patient and the population before decisions are taken about priorities in a situation of financial challenge. Putting more councillors on GP consortia isn’t enough – we need to involve patient support groups, community groups and the voluntary sector. We need to discuss with the patient beforehand what outcome they are looking for, what is achievable and what the risks are – the outcome isn’t merely what degree of movement someone achieves after a knee replacement.
3) Do we already have the necessary tools to measure outcomes?
DH We don’t have the tools yet – we need to work with colleagues in public health who can help give us a whole new set of information. We need to ask patients: ‘What is the best outcome for you?’ And we need to find out why GPs are referring to hospital – is it for a second opinion, investigation or advice? If we record that information it will generate outcomes.
JK We have loads of data, but we don’t have lots of information. We need to look at evidence and best practice. Let’s use our clinical wisdom, our evidence case and NICE guidance to say what is the best pathway and care that produces the best outcomes.
CQUIN needs to up its game. Many CQUINs are rudimentary, based on standard outcomes. Quality payments should describe value added, not: ‘Have you sent a timely discharge letter?’, but: ‘Did you tell the commissioner when a patient was admitted and start planning discharge on the day of admission?’
PC We do have some tools, and more are being developed all the time – it’s a constantly changing and refining process. There are measures that are related to a specific figure such as blood pressure or reduction in particular symptoms, such as in asthma. You can assess reductions in symptoms, hospital admissions or improvements in survival rates and combine them with Patient Reported Outcome Measures (PROMs) to give an overall picture.
We know PROMS are useful and backed by research into their validity. It’s easy to be sceptical, but what patients report is very important in service development.
It will be about transitional change, picking out the easier things to measure and starting with those. It has got to feel real to clinicians. We’ll start with what we’ve got and then further measures will develop over a period of years, probably with a lead-in time of five to 10 years. It will be a journey rather than a big bang.
BG We need better tools. One of the challenges in healthcare is the time lag between input and shifting outcomes. We can do a lot of work this year, but it doesn’t mean lifespan will increase this year, so we end up with a set of proxies such as cancer screening rates. There’s a key role for the NHS Commissioning Board to define high-level outcomes, working with NICE.
4) What will the 150 quality standards NICE is developing bring to the table?
PC They will be very important. The outcomes framework will be based on the NICE 150, which will represent achievable good outcomes. It won’t give us everything we need, but it will be fairly comprehensive. How various consortia achieve a specific outcome may be different, and if some have innovative ways of achieving it this will need to be shared. One can always hope this will really happen.
DH It depends how detailed they are. A high-level framework would be very good so every consortium does not have to reinvent the quality standards for commissioning, but micromanagement will be destructive. Too much focus on the numerical would be very bad. We have to be able to take these standards and commission in a way that suits the local population.
JK They will help to focus contracting, but they should not be restrictive, they should be part of a programme of developing better metrics. We need evidence-based medicine where you have good reason to focus your efforts to measure this or that outcome.
BG It’s difficult to know at this stage, but there have to be clear, tangible goals – otherwise performance against them will be a subjective judgment.
5) How can GP commissioners ensure existing providers are striving towards real outcomes rather than maximising activity?
DH By engaging in dialogue at clinician-to-clinician level at the earliest opportunity. Discussions that are dominated by allegiances to organisations and maximising trust income are dangerous.
Commissioners will either succeed at clinical engagement or have to use competition and say if you don’t achieve the outcomes we want, we will go somewhere else. Some secondary care clinicians are dedicated to their own specialism and will want investment in that. We have to say that we are aiming at what is best for the patient and the wider community, not just one disease area.
PC It’s about agreeing with providers what they have to do to be paid. Commissioners will be setting providers outcomes based on the outcomes framework or targets set by Public Health England relating to lifestyle measures. These are performance measures GP consortia will have to achieve in order to satisfy the NHS Commissioning Board that they are performing. Being realistic, there will be a mix of an activity payment and an element of performance-related pay based on outcomes in the provider contracts much like the current GP contract.
Measuring the quality of service is complex. Some outcome measures will focus on patient experience. In dermatology for instance, often it is about fixing people’s heads, as well as their skin – making them feel empowered and in control of their disease, rather than just slapping on cream.
This is where both the clinical outcome and the patient experience is important, as in most areas of medicine.
BG The main lever will be primary care and secondary care clinicians working together to develop a model of care that improves quality. We need to shift the system from one where the levers are about using contracts as the driver, to one where clinicians define the needs and desired outcomes and the technical detail of contracts follows on from that.
6) Are there any examples of good practice where GP commissioning groups have achieved outcomes-based commissioning?
DH We don’t yet know where the pockets of good practice are. In Taunton, we are doing some work on enablement, going in and asking the patient what they need – which is often not what the assessment says – and I’m sure there are other examples elsewhere.
JK We are in the very early days. There is good practice up and down the country but it’s not yet at the stage where I can say ‘this is happening here, and this is what somewhere else is doing’.
PC It’s too early to have any concrete examples from GP consortia, but there is no doubt there are services around the UK that are getting better results and outcomes than others doing a similar job, and GP commissioners need to learn from them.
The last government thought you could improve performance by setting targets in a top-down way. They were right – you clearly have to have performance targets and they are best set nationally.
The difference is that the new targets will be based less on measures such as waiting times and more on how many people get a good outcome.
BG It feels like we are only at the start of a journey. The examples I hear about are where GPs are leading the contracting process, but we’ve not got far enough yet to have case studies.
7) To get started on this trajectory, what should GP commissioning groups be doing now?
DH Don’t be too focused on setting up your GP consortia, but start a dialogue with clinicians in primary and secondary care. The first priority is to engage with practices, making sure there is ownership and recognition that the registered population is their responsibility in- and out-of-hours. Second, start engaging with the general population, bringing practice participation groups into discussions with the consortia.
JK You need to ensure people have bought into focusing on better outcomes, the clinical process and care delivery. It’s not about ‘is there an accountable officer’, but about how you empower your registered population. Taking a holistic approach to commissioning care for the population has to involve the third sector and a multi-disciplinary approach with professions from nurses and mental health specialists to optometrists – everyone who provides care and influences the determinants of health, not just GPs. What are you doing with your local authority to look at the determinants of health and to use their commissioning expertise?
PC It’s a question of getting themselves organised and starting to think about what their priorities will be for improving the care of the registered population. We have to look at the quality of care and how we get better quality for the same money, or less. Good care doesn’t have to cost more.
Looking after people better can reduce admission rates and follow-ups. Clearly the current pause in the bill has left a limbo situation, but this will be short lived. The outcome of the listening process will,
I suspect, confirm GP commissioning will remain – although the competitive provider element will be altered, which will not disappoint many GPs. I think competition used wisely is very effective in driving up quality, and sensible plurality of provision is good for patients – but less so for clinicians.
BG Have conversations with the contracting team in your PCT, but don’t get diverted into data validation. More investment in coding doesn’t drive outcomes. The whole of the system needs to move into a focus on transformation, not transactions.
Kaye McIntosh is a freelance journalist
The beginning of an outcomes-focused era