Much has been written on the commissioning of urgent care and a good place to start is with “Breaking the mould without breaking the system” by the NHS Alliance and “Avoiding hospital admissions, what does the research show” from the Kings Fund: both are recent and comprehensive. 1, 2 I don’t intend to repeat the details of these publications however there are a few clear themes that are important for CCGs to be aware of as they approach the commissioning of this fundamental area of care.
This is a very complex system to commission however many areas have risen successfully to this challenge. Use the above principles and take time to read the articles I have referenced; they provide an extremely good blueprint with a comprehensive evidence review.
1 Start with the whole system
It would be wise to start by considering the whole system of urgent care provision. All too often commissioners focus on one small part of the system; usually in response to some crisis, and respond with a ‘knee-jerk’ reaction of changing one part of the service without considering the system as a whole. This will frequently lead to the development of a new demand stream rather than the solution that was envisaged. Thus the first important step is to consider all the different parts of the system and then involve all those involved in the provision of the service both in hours and out of hours, both physical, mental or social care and both community and acute care.
2 Focus on primary care
One of the main participants that is often left out is primary care. The provision of primary care has a huge effect on urgent care services and it is crucial that primary care is included as well. Commissioners rarely consider primary care, yet we know that high quality primary care can very successfully manage aspects of urgent care in the community.
For instance, many of the most urgent requests for care are received as calls to GPs for home visits. The NHS Alliance recommends that CCGs instruct practices to call patients back in these cases, so that they can take immediate action for that patient and perhaps arrange a rapid transfer to hospital for a specialist opinion.
The Department of Health’s ‘Transforming community services’ report on quality indicators for community care3 is highlighted by the NHS Alliance, but if services are going to work locally then CCGs need to collect data on cost and acitivty data. The Alliance suggests that, due to the slow development of community service systems, GP practices and OOH services collect the data through their own systems.
Often commissioners struggle with the notion of having providers at the table at all, when considering how to commission. Often members such as the ambulance service or social care or indeed the voluntary sector are neglected. Providers are crucial to help commissioners innovate: get them all round the table at the first opportunity and agree at what point they need to withdraw (this will only really be necessary if a decision to tender the service or part of it is being considered).
3 Get patients to participate in design
One of the foundations of any commissioning process must be the involvement of those who are receiving the service and so whilst it is crucially important to have all the providers around the table it is equally important to listen to those who receive care. Patient stories are very powerful and an extremely useful tool. Commissioners need to seek feedback on all aspects of urgent care and use these case studies in their development of new models or care. It is essential to focus on the interfaces between different care systems: be it primary and secondary or ambulance and primary; there are many boundaries and hand offs, in urgent care provision and these “junctures” are often points of high risk and need careful consideration.
It’s also important to evaluate outcomes of new primary-secondary care interventions, according to the King’s Fund. Its report found that integrating primary and secondary care to provide disease management for patients with certain conditions can reduce unplanned admissions. For instance, managed disease networks in Scotland demonstrated a reduction in emergency admissions for ambulatory care-sensitive conditions in the three years after networks were implemented, though reductions were evident for angina and diabetes, but not heart failure.4
4 Ensure supply/demand data is accurate
Having secured all the key players around the table, the next step is to understand the demand. There is an oft perpetuated myth that demand is unpredictable and can’t be adequately provided for; yet analysis shows that the variation from the mean in any given hour is rarely more than 50%. The reason for queues is mainly that demand has not been fully determined and capacity requirements matched to demand; if this is not examined in depth, and across all pathways then delays will occur. An important step is thus to assess demand and capacity at all parts of the urgent care system.
The variation in demand for urgent care services is predictable, the NHS Alliance argued, and it might be true that your CCG already has the systems in place to create forecasts based on past A&E usage data. The Alliance report adds that the evidence suggests opening new services is opening up new demand for services, only some of which is for urgent care., and that commissioners consider if they are adding value to the local health economy or not .
Knowing the demand and current capacity is only one part of this complex jigsaw. The next step is to review the current evidence on the different types of services: and in urgent care there are many, ranging from GPs in A&E to intermediate care facilities to case management. Evidence is crucially important. All too often services are commissioned with little or no regard to the evidence of their success: frequently relying on little more than the odd anecdote.
Much has been written on the effectiveness of services and the Kings Fund article looks into this in depth. Often it is disappointing to find that there is little evidence for ‘pet’ services. We know for example, that public education to dissuade people away from attending A&E often yields little benefit in terms of behaviour change yet we race forward assuming that ‘this time’ it will be different. Much supportive evidence exists: evidence for strategies such as early senior clinical assessments, or the use of tele-medicine in heart failure: so focus on what works and not pet projects.
Data and measurement are crucial to all areas of commissioning. I’m reminded of the old saying, ‘if you can’t measure it you can’t manage it’: however it is important to get the measures right. It’s far better to have a few accurate and timely measures than lots of poor measures that are so out of date that they are of no use for management.
5 Join up services
There is a desperate need to integrate the care we commission. We are renown at dividing care into neat boxes of primary, secondary, ambulance or social care, yet our patients don’t recognise these boundaries: naturally they expect the care they receive to be seamless; why wouldn’t it be? There is a real need for integration across these artificial boundaries. All too often this is seen to require organisational merger high complex and difficult to achieve: however this is not the case.
Commissioners need to commission joined up seamless services, providers then work to deliver this and merger is only one amongst many ways of delivering, what after all are relatively simple commissioning objectives. Outcomes and measure of outcomes are important here and commissioners need to give careful though to what the measure are that will drive integration. This is perhaps best exemplified in the artificial divide between health and social care. Many areas have pooled budgets between the two systems but all too often in reality it is two separate pools: an artificial divide that fails to adequately meet the needs of the frail elderly.
Paul Zollinger-Read is a medical advisor and primary care lead at the King’s Fund, and a former director of commissioning development for NHS Midlands and East.
Guthrie D, Davies H, Greig G et al. Delivering health care through managed clinical networks(MCNs): lessons from the North. National Institute for Health Research Service Delivery and Organisation programme. http://tinyurl.com/7v9anxa