Dr Steve Kell sets out how GPs can assess local needs and focus on where they can have greatest impact
STEP ONE: Work in partnership
Establishing priorities can be daunting. The PCT has been doing this for years and will have a process based on local and national targets.
Accept the benefits of working closely with experienced managers, but understand that clinical commissioning groups (CCGs) represent a real opportunity to do things differently, to engage clinicians and improve patient involvement.
Find out what happens now – how priorities are set, which national targets must be met and which clinicians have been involved in the past.
There are often lots of ideas on how to improve the process – this is an opportunity to explore these and we can all learn from experience.
For many areas some CCG leads may be new to the processes. Engaging in establishing commissioning priorities is an excellent development opportunity and encourages a new viewpoint. Locally we worked with the PCT to write the strategic and QIPP plans, and presented them to the SHA to encourage real ownership.
Local primary and secondary care will have a good understanding of local commissioning needs. Engage with providers early to understand their development plans, and meet with local GPs and nurses to get their views.
STEP TWO: Know your patients’ needs
Many of us will know our population, and have a good understanding of local issues. Effective commissioning relies upon accurate information and there are many sources of information to supplement our knowledge.
Public health colleagues are key to understanding local needs and have access to many sets of data, which we call profiles. Understand the sources available, the pros and cons of each and what information is used.
Public health observatories often offer easy access to profiles, such as cancer atlases, health inequality maps and lifestyle indicators. This information will be summarised in the joint strategic needs assessment (JSNA). CCGs will have a duty to contribute to this. We have now developed practice-specific profiles to enable us to commission more intelligently.
STEP THREE: Know what your patients want
Having an active patient group is clearly important for any CCG and provides an essential challenge for commissioning in the future. It is important to know what local patients see as the key issues in terms of services and quality. We need to ensure we improve patient experience and its measurement, and are aware of outcome measures such as PROMs that may highlight quality or service issues. Are there services receiving a higher than expected number of complaints which will need to be explored?
In an ideal world, GPs will be commissioning services that meet patients’ needs and wants, but they won’t always match. In these cases, it is important to have a sound information base and clear data to demonstrate to patients why a decision has been taken.
STEP FOUR: Know your providers
The number of local providers will vary between CCGs, and it is essential to have a clear understanding of the services offered and quality issues for each. There will be committees within the PCT collecting this data – now is the time to review the structure and membership of these committees, and make sure there is a strong clinical focus on outcomes.
We are obliged to cover national outcomes but local priorities may be different and you might want to alter them. In areas where CCGs are forming shadow boards, it is essential to decide where these outcomes will be reported. Locally we have reviewed our governance processes and will have monthly performance reports which will no doubt change over time as we develop. These should include primary care. CCGs will not hold GP contracts, but it will be important to understand variation in primary care performance when commissioning services.
A mature relationship with providers will help you identify gaps in services and raise quality issues in a consistent way, and is key for effective partnership working. Having an established system to review quality and service issues is essential, and provides an important framework when working with any new providers in the future as services develop.
STEP FIVE: Know the evidence and bigger picture
There is a huge amount of information delivered to commissioners every week, and it must be reviewed for local impact and priority.
Some of these are national imperatives, such as national service frameworks or national guidance. NICE guidance, for example, needs to be reviewed in a structured way by commissioners and providers, and local services need to be assessed against it where relevant. Establish a system early to deal with these needs, to document reviews and identify local priorities and risks.
An example of this is a best practice pathway, such as fractured femur care. How do local providers and commissioners monitor this? Are patients getting the best stroke care according to new guidance?
Know what current systems are to review guidance and take action on the basis of new documents, and work with governance teams to ensure they are robust.
Some services are low volume or specialised, and will continue to be commissioned at a regional or national level, but with local input.
STEP SIX: Focus on areas of biggest impact
With reduced staff and limited clinical time it is essential that CCGs identify not only areas that are important, but what the priorities are and what is achievable. Where can commissioning efforts make the biggest impact? Does the JSNA or public health team tell us where to concentrate our efforts in terms of disease areas or local geography? A challenge is assessing the impact of potential change, and too often we have to assess likely benefits by estimating reduced admission costs, which often makes clinicians sceptical.
This scepticism is caused by the fact that many GPs believe they are difficult to measure. For example, lowering admission rates for long-term conditions appears positive, but estimating the effect has historically been difficult. Realistic outcomes are needed – GPs have to decide what outcomes to use to measure the impact effectively.
Identify areas where there is a local need, where there are gaps in services, and clinicians and patients agree on the priority. An example in many areas is alcohol services, and we are working to improve this locally, particularly because of rising admissions and morbidity from alcohol. We think this is achievable, there is strong evidence for need, and there are potential financial, clinical and quality benefits.
There are capacity issues in health and local authorities. Knowing what we want and what we can achieve is key to developing strong partnerships to commission services together.
Health and wellbeing boards have the potential to facilitate this, and the commissioning of alcohol services is an example where health, schools, social care and police can work together if a joint strategy can be agreed.
STEP SEVEN: Know your finances
This is deliberately last, although many may put it at the top of the list.
Finances undoubtedly drive the services we can commission, but quality and need should be the main drivers for commissioners. There is a need to make sure services are more efficient and higher quality, and to ensure patients have access to care when needed. There is an increasing sense of responsibility among many GPs and a realisation that without financial control services will be threatened, and that has led to increased clinical engagement in commissioning issues and service redesign.
Locally we have offered clinicians and managers NHS-focused financial training, as understanding the current system is key if we are to work across boundaries and closely with managers and others. It is also important to understand why changes may be needed. We need to be clear if commissioning decisions are based on quality, cost or both, and many who would challenge decisions expect this honesty and transparency.
We aim to ensure that all significant commissioning intentions are evidence based, with clear expected outcomes and patient and stakeholder engagement. Setting commissioning priorities may be daunting, and planning is time consuming but essential. We must ensure planning leads to successful delivery, and that priorities have clear lines of responsibility, work plans and timescales.
Dr Steve Kell is chair of the Bassetlaw Commissioning Organisation, and a GP in Worksop, Nottinghamshire