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Time is not on our side, so CCGs must micro commission

Commissioners have an urgent challenge on their hands with the NHS. They need to deliver high quality healthcare more efficiently against a backdrop of the current economic stresses and demographic changes, such as the increasing number of older adults with complex long-term conditions (LTCs), rising costs and expectations. More than 70% of the total NHS budget is spent on managing LTCs. 

But time is not on our side in meeting this challenge. And commissioning in the way we currently do is unlikely to meet these growing demands because the processes are slow and bureaucratic. In effect we commission in years when we need to start thinking in weeks.

To do this we need to test new ways of delivering care for people with long-term conditions, supported by Commissioning Support Units. New ways that utilise and recognise how information technology has become an everyday part of patients’ lives in recent years.

We know that most people can access the internet from home and large numbers of the population use a smart phone.  These provide several ways to capture and display meaningful information to the patient, showing their vital signs and other health information while maintaining governance requirements.   CCGs can commission services which enable a positive shift in the doctor patient relationship, empower patients to become active participants in their care rather than passive recipients. These commissioned services should allow patients to set goals, action plans and track changes in their health in real time to minimised complications of LTCs to yield better health outcomes as evidenced in studies in the UK and internationally.

There is international and local evidence showing supported self-care can produce better outcomes and we should embrace and develop this further.  To do this, CCGs need a commissioning process which can be used to test out new ways of working on a micro level to see if outcomes for patients can be improved.  In the AC-Model (Fig 1), the focus is on micro commissioning and the processes are quicker, less bureaucratic, less staff intensive, encourage innovation and integration of care. This model of working provides an opportunity for CCGs to innovate and commission on a smaller scale and then use the macro commissioning cycle to scale up across the CCGs using collaborative commissioning.

For this to happen CSUs must support CCGs in the new ways of working, through more streamlined support processes, accelerated decision-making and tools to enable best using of timely data and information. Public health intelligence needs to be aligned with commissioning and business intelligence support to enable CCGs to become ‘intelligent innovative commissioners’ of services. This will require a change in the mind-set of managers forming the CSUs to align with that of the new commissioning processes so that support is targeted appropriately and efficiently to enable and manage change effectively.

While CCGs will be commissioning a wide range of services for their population, the AC-model may be used where specific areas have been prioritised.   Where ‘examples of best practice’  already exist these should be implemented otherwise the pathway should be examined to identify ‘hot spots’ which if altered could transform the service. Expert change managers and all important stakeholders particularly patients would work in a focused way to redesign the pathway in a one or two day workshop focused on the clinical outcomes, experience of patients, financial implications and decommissioning of existing services.  An adjusted pathway would be rapidly implemented by willing clinicians and supported by CSUs, to produce timely results, using both patient satisfaction and clinical outcome measures.  Providing the changes yield positive results this could then be rolled out to more practices across the CCG and shared more widely across the CCGs through collaborative commissioning.

Working in this way can enable transformational change by micro commissioning, which can be scaled up to the macro level using the commissioning cycle.  This model has been tested and implemented to produce an integrated pathway of managing LTCs by introducing patient centred care with online care planning, e-consultations, and telemedicine to proactively manage patient care and introduce immediacy into the system. This work has shown high satisfaction rates amongst patients and yielded significant efficiency savings in service utilisation costs.  For example, using telemedicine in care homes does not have strong supporting evidence from randomised control trials but, using the AC model allowed identification of  a ‘hot spot’ that could be modified using telemedicine consultations yielding 70% reduction in the number of visits needed to address the patients’ needs. This resulted in significant benefits for the clinician, practice, care home and high satisfaction from patients.

In summary, the new commissioning landscape provides an opportunity for CCGs to be bold and innovative in their approach to commissioning for their respective populations.   Choosing to commission as we are now is not an option and will not help us to meet the challenges ahead. We need to use technologies such as online care planning, and telehealth to support greater self-care, and to test out new ways of working. This is needed so we can decommission services which are not yielding patient benefit and allow more rapid, innovative, and exciting ways to make use of QIPP and obtain quality outcomes for the population serve we serve in the NHS.

Shahid Ali is a GP, senior manager in the NHS, co-founder and director of Dynamic Health Systems.  He has been working as a national clinical leader in the NHS Commissioning Board.