To commission services effectively, you need to first find out what your population needs. The NHS Alliance’s Dr Shane Gordon provides a guide
A good understanding of the challenges facing your health economy is vital to help you plan where best to target your commissioning efforts. There is a limit to the time and effort you can target at service redesign in any given year. It makes sense to do the things that make the most difference first. The following steps will help you make a comprehensive assessment of your population’s needs and identify priorities for action.
1. Analyse your population’s health trends
Public health teams collect a wide variety of data, painting a picture of the major challenges in improving the health of your population. A key document is the Joint Strategic Needs Assessment (JSNA), produced jointly by public health departments in PCTs and their counterparts in local government. It is a comprehensive, but sometimes high-level, assessment of the major drivers of demand for health services. It might include assessments of:
• current and predicted demographic profiles
• prevalence of major lifestyle risk factors such as obesity, alcohol and drug misuse, and smoking
• teenage pregnancy rates
• child mortality, morbidity and vaccination uptake
• effectiveness of primary care management for long-term conditions
• incidence and outcomes for major diseases such as stroke, MI and cancers.
The GPs in our recently merged North East Essex GP Commissioning Group have used the local JSNA for the past three years to prioritise efforts on practice-based commissioning. The Association of Public Health Observatories also provides interactive atlases for this type of data, often going right down to practice level.
2. Match your area’s expenditure to its health outcomes
You can use an approach called programme budgeting to ask ‘are we getting the best possible outcomes for our investment, and are we getting them in the most efficient way possible?’. The Department of Health defines programme budgeting as ‘analysis of expenditure in healthcare programmes, such as cancer, mental health and cardiovascular diseases’.
First, benchmark your local outcome and activity data against similar areas in the UK. The recently published NHS Atlas of Variation shows variation between PCTs in England, standardised to demographics, demonstrating, for instance, variation in access to stroke units. The Inpatient Variation in Expenditure Tool gives a similar comparison for elective activity.
You can assess value for money by looking at how much you spend to achieve your outcomes. The Spend and Outcomes Tool (SPOT) plots relative outcomes against relative expenditure, again with data standardised for demographics. It allows you to easily spot (pardon the pun) which areas of health spend produce good value for money and which do not. It also allows you to differentiate big areas of expenditure from smaller ones. The Health Investment Network provides a range of free, online tools (including SPOT, IVET and the Programme Budget interactive atlas) with a detailed explanation of their use.
3. Examine management of long-term conditions
The largest proportion of health expenditure in England goes on emergency, and to a lesser extent preventive, management of long-term conditions. For example, nearly 10% (£10bn) of NHS expenditure goes towards mental health problems. Understanding the effectiveness of our preventive services is key to deciding how to best use resources.
NHS Comparators gives you access to Secondary Uses Service (SUS) data provided by all acute trusts and QOF data for primary care, which is benchmarked nationally, regionally and by PCT (see graph). It requires a username and password which can be applied for on a per-practice basis via the website.
I find the ‘reported versus expected prevalence’ for QOF conditions very interesting. Big discrepancies ask some challenging questions about how assiduously we are seeking disease within our practice populations.
Access to health services plays an important part in preventing an exacerbation becoming an emergency. Triangulation of GP access, out-of-hours and A&E data can allow you to see where access is good or less good. Plotting data by time of day can be particularly interesting – in my PCT, the attendances at A&E peak at lunchtime and just after GP services close.
Another consideration is the change in prevalence for long-term conditions over time. Diabetes deserves close attention as it is a rapidly increasing condition predisposing to many major vascular diseases. Planning primary and secondary prevention is essential to reduce the condition’s future impact. The Diabetes Prevalence Model gives estimates for the prevalence of adults with diabetes in England up to 2030.
4. Assess patient feedback and other ‘soft’ outcomes
Public and patient involvement in assessment of needs and the subsequent prioritisation of commissioning effort will be essential for GP consortia. There will be a requirement to contribute to the development of the JSNA with local government and to have strategic plans approved by the local health and wellbeing board. There will also be a need to engage on a less formal level with the public, to identify future priorities.
Lord Darzi defined three aspects of quality in health services: safety, clinical outcomes and patient experience. Patient experience has commonly been measured using satisfaction surveys. These are useful, although sometimes difficult to interpret because of lack of standardisation. One particularly helpful measure is the ‘net promoter score’ – the proportion of people who would recommend a service to a friend.
One recent development is the systematic measurement before and after treatment of patient-reported outcome measures (PROMs). During 2009/10 these were measured for four procedures: hip and knee replacement, varicose vein surgery and hernia repairs. The results are available in spreadsheets by trust with benchmarks to national data. There was variation in the threshold of symptoms at which surgery was offered and the improvement in symptoms and quality of life after surgery – for example, 51% of patients did not show an improvement in quality of life after hernia repair.
5. Focus on smaller populations within your cluster
One challenge for GP commissioning will be to develop sophisticated, sensitive commissioning for local populations. Ways will need to be found to identify groups with specific needs, particularly small groups who contribute more than average to overall demand – for example minority ethnic groups, the travelling population, students, substance abusers and the homeless.
Voluntary-sector organisations can provide a useful insight into the needs and patterns of behaviour for these groups, whose requirements might otherwise be missed among higher-level data.
Getting down to practice-level data also starts to show the unique profile of each small population. A sophisticated approach to needs assessment will develop different priorities for action in each GP practice within a consortium. In the last 18 months, we have developed bespoke performance indicators for each practice in North-East Essex. This allows each practice to focus its efforts on health issues of particular relevance to its population.
Dr Shane Gordon is co-lead of the NHS Alliance GP Commissioning Federation and a GP in Tiptree, Essex
Five steps to assessing population need Click here to take the assessment This module is worth a suggested 1 CPD hour