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Commissioning whole pathways to drive up quality

Dr Steve Laitner explains how NHS East of England is helping GPs to commission in a groundbreaking way, whereby the total patient journey is co-ordinated by a single provider.

A colleague who had worked in a number of different sectors in the past, including the oil industry, once remarked to me that healthcare was by far the most complex sector he had worked in.

Yet despite being the most complex, the health sector tries to micro-commission, micro-contract and micro-manage all the various providers along the most complex supply chain known to man.

GP commissioners are finding the reforms difficult to implement because of complex contracting arrangements with multiple providers – just as PCTs have struggled with commissioning, but with far greater management resources.

Too often it is the patients who bear the brunt of the fragmentation of the healthcare delivery system, and they become deeply frustrated with the lack of joined-up care and the lack of co-ordination and integration of services.

A critical ingredient in the success of the healthcare reforms will be the speed at which GPs acquire the expertise to manage these budgets and transform complex healthcare delivery systems.

Some of them are already on their way to doing this.

GP commissioners have a choice. They can either continue to build up the necessary types of skills in house or acquire them through a partner or supplier.

But they have another, much more important, choice. They can continue to do what their commissioning predecessors did, and micro-commission and micro-manage complex healthcare systems and pathways.

Or, they can do what other industries do – contract with a prime contractor who is accountable for the whole ‘job'.

There is a growing realisation that commissioning is never going to succeed if we expect commissioners to hold multiple contracts with various providers for each area of health need.

At NHS East of England, we are looking to assist PCTs and GP consortia who want to commission a new model to join up services – an integrated pathway hub (IPH) delivered by a prime contractor.

This model involves a single accountable provider being given the total budget for a programme, such as respiratory health, or a care group, such as the frail elderly, and being accountable for the quality and cost of the entire patient pathway across primary, community and acute care.

The prime contractor will itself be providing a substantial part of the care pathway – community-based specialist services as an alternative to hospital outpatients as well as managing the rest of the pathway through subcontractors.

How the model works

Let's take a respiratory pathway. At the moment there are contracts for smoking cessation, primary care, pulmonary rehabilitation services, home oxygen and inpatient and outpatient care. At the moment, commissioners are trying, but struggling, to co-ordinate all these different contracts from outside the healthcare delivery system.

Under the IPH, the prime contractor receives a programme budget to deliver specialist services in the community and subcontract providers like hospital inpatient and oxygen services. So the prime contractor is both providing and subcontracting.

This creates strong incentives to manage complex and long-term conditions effectively and focus on earlier and cheaper interventions.

A key difference between the IPH model and the current one is that the IPH would not be affected by existing financial incentives that can contribute to unnecessary escalation at inappropriate expense.


There are a number of benefits to the IPH model. No large organisational change is needed.

It mitigates the risk for GP commissioners as the prime contractor has taken responsibility for the budget, so there is no risk to the consortium of overspending for that programme.

Contracts will be time-limited, creating an incentive to deliver continuous improvement. The focus on outcomes, built into the IPH model, is commissioned through an outcome-based, high-level contract.

The contract will not be over specified, which makes the job of the commissioner easier and also makes the provider more free to innovate, while still delivering the high level outcomes required.

It also means we can finally move to a ‘biopsychosocial' model of care as providers will have a real incentive to improve patients' lives – and as GPs we know full well that patients' solutions often lie outside the health system.

Some programmes, such as those for the frail elderly, lend themselves to being a service jointly commissioned by health and social services.

Delivering QIPP

East of England is drawing up a tender document for the following programmes:

• respiratory

• the frail elderly

• musculoskeletal.

We are assisting PCTs and GP consortia in commissioning services this way, via open competitive tender.

We have had solid interest so far and are confident that all three of the above programmes will be commissioned in this way.

The model is one of the workstreams of the central QIPP initiatives. I have no doubt that by commissioning in this way and giving the provider organisation responsibility for the whole system, we can create substantial quality improvements for patients.

Early feasibility research suggests QIPP initiatives, of which the IPH is one of several, could save £603 million per annum in the East of England.

Defining outcomes

In terms of specific outcomes for the programme, we are still working out the details – but we are clear on the commissioning and service model and the sort of high-level outcomes we will be looking for. But we also know there are a number of tools out there to facilitate the commissioning of outcomes.

For musculoskeletal conditions, for example, there is the Oxford hip and knee score. For respiratory outcomes, we could measure these by including reduction in smoking prevalence or reduction in the number of exacerbations resulting in admission.

We will, of course, use nationally agreed service outcomes such as those being developed by NICE. We will also ensure that we involve patient groups, as well as generalist and specialist clinicians, in the development of the specifications.

Where the pathway starts

The pathway begins from when a patient is at risk of a disease.

Patients will still access their GPs, and we would in no way chip away at that traditional GP model – in fact, the model relies on the prime contractor supporting and, where necessary, challenging primary care to deliver better care.

Incentives such as local enhanced services could be an important vehicle for the prime contractor in their subcontracting role.

GPs would initiate a referral to the pathway hub when they feel they need help managing a patient.

They would be more able to receive advice and guidance on treatment so that a more traditional referral is not required. Some patients would be able to access the IPH directly when they are under their continuing care.

We would expect the programme and pathway provider to innovate in how they provide this advice – for example, rather than referring the patient for an outpatient appointment, the GP could pick up the phone and speak to a consultant while their patient is still in front of them.

We also envisage more services being provided closer to home for many patients.


If a pathway prime contractor had to use the services of a hospital, it would be charged the PbR rate – but this is not passed on to the commissioner.

The default position for a GP in a consortium that has commissioned an IPH would be the prime contractor. If for a particular clinical reason, or by the patient's choice, the decision was made not to go to a contractor, the case would be made to the prime contractor and referrals to other providers would need to be facilitated in accordance with patient choice and clinical need.

Once the patient has been seen by the pathway hub, if the patient still wished to exercise their choice and go to another provider they could do so.

Interest so far

We are truly agnostic about who the prime contractor provider is likely to be for any pathway.

Because of the multidisciplinary input into the pathways, there are likely to be joint ventures bidding for the pathways – say an acute trust with community services or a third-sector provider.

Some GPs might also wish to be part of a joint venture, but it is likely they would then not be able to be on the board of the GP commissioning consortium – any potential conflict between the commissioning and specialist service provision role would need to be openly declared and carefully managed.

I think the third sector is going to be crucial to this. Organisations like Diabetes UK, the British Lung Foundation and Arthritis Care are highly valued by patients and their carers and not only have a role in redesigning services, but also in their provision.

What we shouldn't do is confuse the people – therapists, nurses, specialists – with the organisations they work for. So what we don't want to see is commissioners feeling they have to make the acute trust the prime vendor, just because they need the consultants that work there. Other people can employ consultants, or prime contractors can contract an acute trust for consultant time.

We've had a huge amount of interest from community trusts, acute trusts, primary care providers and independent sector organisations.

There has been some concern among GPs and some managers about open competitive tendering of services, as we know not everyone signs up to competition in health care.

My view is that competition is a means to an end. When used wisely to drive innovation, collaboration and integration, it can ensure commissioners get what they want and what the public need.

We can use competition to drive integration. And we want the best-placed providers and the best ideas, from within the NHS and outside it.

Dr Steve Laitner is a GP and associate medical director for NHS East of England. He is clinical adviser, elective and diagnostics, to the Department of Health

Commissioning whole pathways to drive up quality