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Commissioning to reduce costs



Dr Charles Alessi sets out his top tips to ensure your commissioning decisions are helping reduce costs in your consortium

Total health spend is being pegged to very small increases over the next few years, of just 0.1% per year in real terms. As a working maxim, I would suggest we assume spend is broadly being kept to what it is now.

This has significant implications, since under GP commissioning, we will have a duty to remain within the budget for our population, and so when we spend more in one area we need to spend less in another.

This is not necessarily going to be welcomed by our colleagues within acute and mental health trusts, who have grown used to a world of increasing resources. Here I suggest some tips to help your commissioning consortium keep within budget and for generating efficiency savings.

1 Set clinical priorities

For the first time, budgetary determinations are part of our core function. The necessity to implement NICE remains, but it is moderated by the requirement that the changes we propose have to be prioritised and affordable.

We have to live within our means, and that means targeting funding at those areas of clinical care we decide are really important. If we are expected to fund new pathways or drugs, we will have to ensure that the overall effect on our budget is cash-neutral.

2 Prepare an overarching plan

It is very easy to get waylaid and submerged in detail at the start of the process of clinical commissioning. To avoid doing so, I suggest GPs concentrate on developing an overall game plan. What are you trying to achieve, who for and at what pace? Whatever you propose must have clear aims and outcomes. If you cannot measure the difference, then it is probably not worth doing. And you need to suggest a plan that is both financially sustainable and, crucially, enforceable among your colleagues.

3 Gain consensus among GPs

Ensure there is a consensus among GPs around the direction of consortium policy, and on the contracting experts you have signed up to help with the process. This may not be straightforward – inevitably, there will be some who believe the system you had in place was the correct one, and change can always be painful. If you do not get the result you had hoped for it could be that your colleagues’ support was weaker and less consistent than it had appeared to be. In my experience, it is this fact rather than obstructive behaviour in secondary care that is all too often the major determinant of success or failure.

4 Focus on unnecessary use of secondary care

In Kingston, we have a referral management system, which routes all referrals through a central portal from where they are sent via Choose and Book to providers. It’s also important to benchmark referrals from GPs as a means of addressing unnecessary variation. But not all referral activity is generated by GP practices – substantial costs can be incurred through consultant-to-consultant referrals. We’re currently proposing a new way to manage these referrals, applying a similar process to the post-payment verification system applied to primary care by PCTs.

5 Enrol management support

GPs are the new commissioners – but we do not need to be the new contractors. Partnership is the name of the game.

We need to use the transition to get an understanding of the politics of commissioning and the big picture, not the minutiae, which should be left to the specialist contractors and a few clinicians who will specialise in commissioning. GP commissioners need to get a grounding in the nuts and bolts of contracting, but should resist the temptation to become experts.

6 Target key opinion formers

Engagement with secondary care clinicians is the key to effective clinical commissioning, and we can use the relationships we have to get a better understanding of how hospitals really work and how to suggest potential change. The relationships with your management support are of huge importance here. Use their system memory to identify and target the key opinion formers in secondary care.

7 Take baby steps to change

The key to success is aiming for small but achievable change. Once you have a track record of success, further change becomes easier. NHS commissioning is littered with examples of good intentions and schemes that just did not deliver.

It is possible the provider will be less than co-operative and even obstructive.

If you are aiming to fundamentally alter a pathway, concentrate on a specific area first and negotiate around achieving a small change. The mere fact you succeed increases your credibility.

8 Be rigorous about monitoring performance

It is essential to take a rigorous approach to monitoring the metrics you have agreed. Inevitably, you will find the metrics do not quite capture what you hoped and any competent provider will find ways to partially circumvent the systems you have spent so much time painstakingly putting into place. It is important you are not disheartened, as this is a learning experience and you will think differently next time.

9 Audit all coding

Ensure your management colleagues are using tested methods of checking on duplicate activity, up-coding, overtreatment and other such mechanisms now used routinely to increase activity and cost.

You should compare primary care records, secondary care records and billing data to assess the accuracy of secondary care coding. Look at what was requested by the GP, the treatments carried out, how they were carried out, how they were coded and what was billed. And apply a penalty for miscoding – large enough to change behaviour.

10 Learn from your successes – and mistakes

Learn from both what went well and what went less well. You might act differently next time, but you have achieved far more than a colleague who has not even attempted to learn new skills.

Next time you are in a position to use clinical commissioning skills, you will be in a far stronger position and you will be more confident in making your voice heard. You have the success to show – and no doubt the scars, too.

Dr Charles Alessi is executive member of the National Association of Primary Care, and leader of Kingston consortium pathfinder

Commissioning to reduce costs