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How we can create new levers – and get them pulled

The days of using extra funding to improve quality or health outcomes through commissioning are gone, at least for now.

This is the age of cost improvement, of getting more for less. The figures involved are huge but we can at least put aside the £20bn as we get on with the day job. Commissioners, clinicians or otherwise, face a more fundamental challenge. Put simply, as commissioners we want to reduce the costs of service provision without damaging quality but very few of the levers – skill mix changes, process and workflow, technology – are within reach.  Providers, by contrast have the levers but limited or conflicting incentives to pull them: they generally want to do more activity and earn more income. If they do manage to reduce costs then the mechanism for passing the benefit on to commissioning bodies is uncertain to say the least. So we resort to the only methods we have - arbitrarily limiting access to care or reducing the quantum of care offered to each patient.  These measures may work in the short term but they are crude, unsustainable and may store up problems for the future.

So what is the alternative?  We could get involved in provider management, perhaps by looking at workforce and other inputs.  Not ideal as commissioners generally lack detailed knowledge to challenge ways of working. 

We could go back to block contracts. This caps the financial risk but leaves us with even less ability to influence quality and practice. Superficially attractive but certainly a retrograde step

We could change the contract currency. For example for patients with chronic illness, perhaps where treatment options are variable and complex we might devise a ‘year of care' payment that gives freedom to the provider to innovate but tie this to improvements in quality or efficiency. This is a promising approach that relies on just one critical factor – data, not just any data but good data at a patient level, what treatment they have, what it costs.

The carrot for providers is a new-found clinical freedom and the substitution of paperwork to support processes (individual funding requests, prior approvals forms) by clear objectives to improve clinical, financial and patient experience outcomes.

For this to work we need to understand how changes in treatment in the contracted service impacts elsewhere. For example greater freedom in a service to manage patients with rheumatoid arthritis should lead to more rapid and sustained management of disease measured by DAS score at patient cohort level. The benefits for commissioners would be lower hospitalisation costs, less risk on high-cost biologic drugs and, outside the NHS, reduced bills for social care.

For this to work we need to link up the datasets at patient level. This is not technically difficult.  We have the NHS number and ready-made datasets in primary and secondary care. In the short term we may need to collect some additional data but this will not be onerous and will help to inculcate routine collection of data in electronic form. The spin-off benefits would be huge including the identification of optimum treatment regimes, steady improvements in data quality, better commissioning decisions and so on.

The costs of this type of approach are not high at a local level and will come down drastically every time we do it until this type of approach becomes the norm and we get to the position whereby no commissioning decision is made without this type of detailed, patient cohort data.  It is not really a question of whether we can afford to do it but whether we can afford not to.

Tim Jones is an NHS commissioning specialist working with WG Consulting, a Department of Health-approved supplier of commissioning services to the NHS