If the promised new world of GP-led commissioning is to work well it will need excellent data as its bedrock. Tom Mulhern, explains where to find the data commissioners require to make informed decisions and what more is needed for the future.
Many GPs I meet have a detailed understanding of key issues over electronic patient data.
In fact they frequently have strong views over issues such as data quality and availability. They often feel frustrated by the persistent problem over how to get the information they need to make the fully-informed decisions on patient services.
What makes the situation even more problematic at the moment is that the future is so uncertain. With the Health and Social Care Bill performing a strange and lurching dance through parliament it is far from certain just what legislation, if any, will finally gain royal assent. But the best guesses are that GP-led commissioning is on the way.
Accessing the right information
There will be extra demands on staff at every practice in England with managers, nurses and clinicians alike becoming the builders of an entirely new NHS structure. While they are getting on with that job, they will be expected to save billions of pounds and improve patient outcomes. It’s a tall order and is only possible if they can access and make effective use of the information they need for each of the three parts of the commissioning cycle – strategic planning, service procurement and monitoring and evaluation.
So what data is out there, and is it fit for purpose?
Had the National Programme for IT (NPfIT) delivered the hoped-for comprehensive national care record system, instantly accessible to 30,000 GPs, then that would have provided an important route to the future. All that fabulously rich information could have been pseudonymised, so no individuals were identifiable, and used for all sorts of studies and analysis.
As we know the national programme has not achieved its original aims. In addition, many trusts are way behind schedule on the DH’s pseudonymisation implementation plan, to encrypt patient identities so the information stored in their records can be used to monitor performances and study trends.
Soft and hard data
Despite serious problems over access to extensive and reliable data, a lot of great work is being carried out in both the public and private sectors. It will certainly pay dividends for anyone involved in commissioning to get an idea of what is out there, its potential, and where the gaps are.
Another big plus is that GP practices have tended to be very good indeed at accumulating information, which could be absolutely invaluable for the purchasing and measuring of services from competing providers. Their own patient record systems are full of hard data, the kind of material garnered through scientific measurement and observation, which can shed light on all sorts of things, such as the prevalence of particular illnesses.
Likewise, they have lots of soft data from things like patient and family interviews and surveys, which offer a very different but profoundly important perspective on services.
While hard data is absolutely essential for commissioners doing number crunching – for example how many hip replacements a given hospital performed and the length of stay – it never provides a complete picture. This is because it does not describe the actual patient experience, which can be vital in showing deep flaws in a system which numbers alone would indicate is top quality. Of course, there are recognised shortcomings in today’s methods of measuring patient experience, but they are improving all the time.
I think that the close and ongoing relationship between GPs and patients puts them in a unique position to understand whether people are getting the care they deserve.
It’s not only government-sponsored questionnaires that show what is going on, and indeed, it would probably be better if GPs had a substantial say in how NHS success or failure is measured.
In the meantime GP-led commissioning will need effective ways to share and utilise the information that practices hold.
Detailed data for commissioners
Many GPs are acutely aware of issues around data quality and validation. Practice-based commissioners, who have frequently depended on what comes from PCTs, know that it is not always as good as it could be. This is a problem that affects much of what is available at every level, local, regional or national.
Nonetheless, The NHS Information Centre (www.ic.nhs.uk/) is an excellent first port of call for GPs in search of statistics. It also provides WCC (world class commissioning) data packs – designed for use by PCTs – which cover some 250 indicators. These bring together data from multiple sources to allow local comparisons to be made against national averages, so they can benchmark and follow trends www.ic.nhs.uk/wccdatapacks.
The Centre also has a jargon buster (which complements the one provided by Practical Commissioning), which is excellent for distinguishing your SAS from your SDS. Much information used in planning, commissioning, auditing and managing services comes from the Secondary Uses Service (SUS) and is intended to be a comprehensive source of data to underpin reporting and analysis ((www.connectingforhealth.nhs.uk/systemsandservices/sus). What it offers can, if used effectively, can be of tremendous value.
For example, the Hospital Episodes Statistics (HES) are currently the best option we have for looking at how much is spent on patients with particular conditions – and offer a complete set of inpatient, outpatient and A&E information back to 2004/5. It also allows GPs to make certain comparisons between the ways that practices make referrals and do their commissioning.
Part of SUS, the HES data is among the most vital for commissioners. It allows GP practices to review their own commissioning of services and compare it with others, locally and nationally. It also allows them to benchmark themselves by a set of comparators. HES data covers acute hospitals, primary care trusts and mental health trusts and the care provided to NHS patients by the independent sector, care given to private patients in NHS hospitals. The records contain individual patient information including:
? clinical details on diagnoses and operations
? age group, gender and ethnic
? time waited and date of admission
? where the patient was treated and the area in they lived.
Some data goes back as far as 1989 onwards, and some 12 million new records are added each year. There is outpatient attendance data from 2003 onwards, with more than 40 million new records a year.
Secondary Uses Service is intended as a comprehensive source of anonymous patient-based data for NHS planning, commissioning and auditing of clinical practice. It uses information from the commissioning datasets provided by all secondary care providers in England, which detail all the patient services they have provided, including Payment by Results. SUS is delivered by the NHS Information Centre and NHS Connecting for Health.
Part and parcel of this is NHS Comparators, a free comparative analytical service for commissioners, which makes use of SUS, QOF and GP practice demographic and prescribing data ((www.ic.nhs.uk/nhscomparators). What I would warn about – firstly declaring my interest as the CEO of a healthcare IT company – is that I think this analysis service is useful to a point, but no further, as it doesn’t provide what is really needed in order to make a shift towards commissioning on the basis of quality.
Somewhere else GPs might like to look, if they are not already signed up, is NHS Evidence www.evidence.nhs.uk which is managed by NICE and aims to gives access to evidence-based clinical and non-clinical evidence. The idea is to help those in health and social care make better decisions.
One last suggestion is the HPI (Health Poverty Index) tool, which is intended to allow comparisons to be made between different geographic and cultural groups www.hpi.org.uk.
It’s certainly the case that differences between groups and geographies are a crucial factor in planning services, as is the need to tackle health inequalities.
The big picture
There are a number of interesting publications that discuss the kind of skills and resources needed in GP-led commissioning (the BMA has lots at www.bma.org.uk, so has the Royal College of GPs Centre for Commissioning ww.rcgp.org.uk/centre_for_commissioning.aspx, or there’s the GP Commissioning Portal www.gpcommissioningportal.co.uk or the National Association of Primary Care www.commissioningresource.net/).
What I think is vital is the ability to ask the right questions. For this it can be immensely useful to get beyond the data sources which are specifically aimed at commissioning and look through some of the big picture material. Some are national, while others have regional or local breakdowns, but they can provide invaluable ammunition for anyone involved in discussions over service contracts.
The NAO (National Audit Office) has recently highlighted major wastages in trust procurement and in the use of high value equipment such as CT, MRI scanners and linear accelerator machines (linacs). Use it now as it’s up for abolition ww.nao.org.uk/sector/health_and_social_care.aspx The ONS (Office for National Statistics at ww.statistics.gov.uk/hub/health-social-care/index.html pumps out huge amounts of information and produces HSQ (Health Statistics Quarterly).
There’s a short document, Information needs for GP Consortia, produced by the University of Nottingham, which is an invaluable read for all GPs www.primis.nottingham.ac.uk/attachments/article/649/Information_needs_for_GP_Consortia_Jan2011.pdf
An area of concern for commissioners is that the NHS does not measure nearly enough quality indicators. However, there is great data for essentials such as mortality and readmissions rates, which reveals a great deal.
Another is that there is a four-month time lag in data. This is not only significant because it’s important to know what is happening at the moment, rather than next season, because commissioners may be working to a very tight annual commissioning cycle. This makes it imperative to have timely information to help them determine where to allocate their finite resources.
To get an idea of how currently available data can be turned into a really valuable resource for GP commissioners look at Map of Medicine (www.mapofmedicine.com) . Ultimately I hope that GPs will push for ever-more meaningful data, this would be in their interests as commissioners and because of the patient-centred nature of their profession. I have hopes that this could lead us to a point where HRG-based tariffs are morphed into a new approach where the actual patient pathway becomes the basis of service contracts – simultaneously delivering best practice and value for money.
Tom Mulhern is founder of healthcare business intelligence solutions provider Ardentia