Using best-practice examples can help GPs commission. But it needs to be done with care, say Claudia Roginski and Dr Emmanouil Gkeredakis
Over the past 18 months, a multidisciplinary team from Warwick University has been conducting a large-scale study of the role of evidence in commissioning. This has focused on the use of evidence in redesigning pathways and procuring services that promise higher-quality and more efficient outcomes. In particular, we looked at how GPs can learn from best practice elsewhere.
Why use best practice?
Examples of best practice are often used and seem to be a rich source of evidence for commissioners. The fact that a pathway has been implemented elsewhere makes it concrete and real. There are also time benefits, since such examples provide evidence on multiple aspects of service redesign.
Though still preliminary, the research has provided valuable insights into how best practice can facilitate the commissioning process.
The 120-plus commissioners interviewed or observed by the team found best practice can help:
• develop the actual specification and procurement of services
• ensure services are well specified, quantified and costed
• put mechanisms in place to ensure specifications are adhered to and that the intended outcomes are achievable.
Where can you find examples of best practice?
Insights from interviews suggest best practice can be identified in a number of ways, including:
• systematic search, often with the support of commissioning library services and from various sources (such as NHS Evidence) – many examples of best practice are reported in published and grey literature
• approaching former colleagues with commissioning experience in a particular area of service or liaising with other commissioning organisations that have faced similar challenges
• participating in communities of interest (such as NHS Primary Care Commissioning network, regional networks and NHS Institute for Innovation and Improvement)
• recruitment of personnel, be it a provider or commissioner, with experience of a different pathway design
• attending relevant conferences and reading articles in newsletters and websites where rich case studies are reported
• travelling to sites (in the UK and abroad) to observe, first hand, how pathways are working in the real world.
How can you use examples of best practice?
Best practice is not a panacea – a large number of senior commissioners reported how challenging it is to translate examples of others' best-practice or gold-star pathways into robust specifications. It was even more challenging to build them into contracts with providers.
Some lessons learned:
• Always question ‘best practice', even if it looks convincing and credible. Examples of best practice need to be critically reviewed. What works and makes good sense in one context may not be suitable in another. The particular commissioning needs and realities of the local context need to be taken into account.
A example can be helpful here. In one organisation, the redesign of the adult diabetes pathway was based on documented models of care. In particular, best practice from a systematic literature search suggested ways for the development of a local community service. The role of specialised community nurses was seen as crucial. Yet, the redesign process was stymied by local arrangements for community nurse contracts.
The specialised community nurses in the best-practice area were employed by their local community provider. In contrast, the nurses in the commissioning area were employed by the local acute trust. This meant that the attempt to emulate best practice by moving the service from secondary care to primary care quickly ran into a barrier of complicated employment arrangements.
• Best practice in one part of a pathway will not help you if you go wrong at other stages. Successful service and pathway redesign may face roadblocks because too much emphasis is put on a few types of evidence or because examples of best practice are not used well or at the right time.
Another example from our study was a service redesign project where commissioners emphasised the need to develop the best-service specification for a community service. But they pursued this without first considering their procurement options and contracting models. As a result, serious delivery roadblocks only emerged when there was a rushed handover from service designers to the service commissioners and procurement team.
The community service specification lacked robust performance measures, contractual monitoring requirements were fuzzy, and the proposed pathway, costed at such a late stage, proved to be very expensive.
With the benefit of hindsight, these commissioners acknowledged that they needed to consider examples of good practice for contractual issues as well as different procurement routes at the very beginning of the process.
The different groups involved (finance, information, commissioners, public health and providers) needed to work more collaboratively throughout the pathway development and commissioning process if they were going to extract real value from best practice.
To use best or even good practice more effectively, future commissioners need to put more emphasis on the following:
• Put ‘best practice' examples in context. What makes them successful may actually be dependent on specific features of organisational history or culture, local geography, and social or financial pressures.
• Critically review examples, not merely for the credibility of their source, but also for the relevance to local needs.
• Identify, facilitate and balance contributions from different experts (commissioners and clinicians) – with effective collaboration among experts, the practicality of a proposed ‘best' pathway can be better assessed.
• Use multiple sources of best practice and look into a variety of both successful and failed examples.
• Think carefully about when, not only where, best practice examples can be used most effectively.
Claudia Roginski is head of information at NHS Coventry
Dr Emmanouil Gkeredakis is research fellow at Warwick Business SchoolApplying 'Best practice' to commissioning