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In depth

Commissioning in the new NHS: how to get involved and influence service development

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With the coming radical changes in healthcare commissioning, nurses should engage with local plans to develop GP consortia to ensure their voices are heard

Author

Yvonne Sawbridge, MSc, RHV, RGN, NNEB, is director of quality and nursing, South Staffordshire Primary Care Trust.

Abstract

Sawbridge Y (2010) Nurses can play a vital role in the healthcare commissioning to shape services and improve care. Nursing Times; 106: 33, early online publication.

Nurses have the opportunity to shape healthcare services by getting involved in the new commissioning consortia outlined in the recent health white paper. This article explains the process of commissioning, showing how nurses can use their skills to influence the development of services and improve the quality of patient care.

Keywords Commissioning, GP consortia, Quality

  • This article has been double-blind peer reviewed

 

 

Practice points

  • Nurses interested in becoming involved with commissioning should:
  • Familiarise themselves with common commissioning terms and the commissioning cycle;
  • Find out where their local commissioning groups are;
  • Build relationships with professional executive committee members;
  • Shadow a nurse working in commissioning;
  • Identify ideas that would improve quality for patients without extra costs;
  • Find people to help them write this up as a business case and present it to their commissioners.

 

Introduction

The government’s recent white paper signals radical changes in the way NHS services will be organised (Department of Health, 2010), with commissioning devolved to GP consortia. Nurse involvement will ensure commissioning includes a holistic nursing perspective and that patient services are redesigned and improved.

Commissioning may seem bureaucratic, done by administrators working in isolation from the real world of patient care. Nurses often struggle to understand what commissioning is, and assume it has little to do with them. This article aims to demystify it by outlining some common terms and activities, and by articulating why nurses need to understand and become involved in the process. It also discusses the concept of quality assurance.

What is commissioning?

Commissioning is a cyclical activity (Fig 1) and has at its heart the needs of both the public in general and patients in particular. It encompasses both groups because public health activity – such as smoking cessation - is also commissioned, so the word “patient” is too restrictive for the whole range of services commissioned using NHS funds.

The cycle starts with a needs assessment of those living in the geographical boundaries of a primary care trust, as the DH currently allocates population based funding via PCTs to spend on NHS services. This is known as devolved commissioning, and recognises that it would be impossible for central government to design services flexible enough to respond to local needs.

This need for flexibility is one reason why the coalition government is handing the NHS budget directly to GP consortia, as GPs are seen as the key professionals locally who know their patients’ needs, and what should change in the system to accommodate this. Nurses must be confident about their potential contribution to this activity, both now and in the new system, and find ways to influence commissioning decisions.

The component parts of the commissioning cycle are familiar steps for clinicians: assess, plan, act, evaluate. The only difference is the words. It is easy for nurses to familiarise themselves with the language of commissioning simply by being in and around it, and picking up a basic understanding of the main terms used.

Key steps in commissioning

Commissioning activities consist of several technical tasks, including contracting and procurement. While these may sound like complex sounding steps, they can be likened to the steps taken in many everyday tasks. For example, if you buy a chicken sandwich, you start to assess what you want - brown or white bread, with or without mayonnaise. If you had to write this down, the description would be described as a specification in commissioning terms. This is an essential part of the contracting process - assessing and then defining what is needed.

It is crucial at this stage to ensure people with the relevant expertise are included; without this knowledge commissioners rely on the provider’s quality processes and, when that is translated into millions of pounds worth of service provision, these safeguards alone may be insufficient. This is why clinicians must be involved in commissioning.

In terms of procuring a sandwich, you are likely to consider factors such as convenience, best value for money and quality, and you would also think about past experiences. Having weighed up all these factors, you would then buy it (or send someone else with the right information or service specification). This is known as procurement. If the service is big enough, or brand new, a tendering process is built in, which allows providers to express their interest and a panel then decides which best fit the criteria.

Once a product or service has been procured, it is important to evaluate it, to generate information to feed into the contracting process next time. If you could not find anything to meet the exact specification at one shop you would want to remember that next time, and note whether you had to change the specification or supplier (provider).

Including quality

The NHS next stage review defined quality as having three elements: safety, effectiveness and patient experience (DH, 2008). For the public, this can be put into a set of questions:

  • Safety: “Will I be OK?”
  • Effectiveness: “Will it work?”
  • Patient experience: “How will it feel?”

The DH (2008) described the “quality landscape” as having seven steps, outlined below.

Bringing clarity to quality: this relates to the role of the National Institute for Health and Clinical Excellence and the use of NHS Evidence to ensure a strong framework governing service delivery.

Measuring quality: This has always been challenging to do, at least from the patient experience perspective. It involves establishing clinical dashboards and patient reported outcome measures (PROMs) and (patient reported experience measures (PREMS).

Publishing quality: every trust has to publish a quality account each year. This demonstrates that quality is accorded equal importance as finance, since financial accounts have long been published annually.

Recognise and reward: the Commissioning for Quality and Innovation (CQUIN) payment framework means that trusts sign up to deliver certain quality improvements. If particular standards are not delivered financial rewards are withheld.

Raise standards: a national Quality Board and Quality Observatory have been established to support the quality agenda.

Safeguarding quality: the amalgamation of the regulators into one – the Care Quality Commission - and the development of new methods for regulation are a crucial part of this quality landscape.

Staying ahead: the range of initiatives banded under this heading includes best practice tariffs. For example, if the pathway for patients includes certain steps and agreed lengths of stay, trusts will only be paid for that pathway even if they deliver a different service or longer length of stay. The Health Innovation Council and academic health science centres have also been developed to ensure that the quest for evidence based improvements is rigorously supported.

How do commissioners do this?

Currently PCTs have to demonstrate their capabilities as commissioners by meeting the requirements of World Class Commissioning (WCC). Many nurses have been involved in collecting evidence for the Standards for Better Health assessment and this is a similar framework.

There are 11 WCC competencies, which include elements such as procurement and contracting skills, and quality and innovation; these must all be supported by self assessment and evidence to arrive at a score for each competency. This information is published each year, so the public can judge whether their PCT is doing its job properly. It is not yet clear how commissioning competencies will be developed and assessed in the new system, if at all.

One of the commissioning competencies covers the ability to set contracts which include quality standards that are measurable and seek year on year improvements. This presents a challenge. How do you choose which measurements describe a good patient experience? Hospital food and car parking are extremely important to patients, and are relatively easy to measure, but how do you systematically demonstrate that compassionate care is being delivered?

What do quality standards look like?

All three components of quality have to be covered in these standards. One example for each area might be:

  • Safety: reducing healthcare associated infection rates by 30%;
  • Experience: setting up a mechanism to capture patients’ views, establishing a baseline and showing improvement of 20% by year end in three out of five categories;
  • Effectiveness: demonstrating full compliance with NICE guidance.

How are they measured?

Once these standards have been developed, written into the contract and agreed by providers, they must be monitored. This can be explained using a manufacturing analogy. In retail, if a brand of cake is marketed as a quality product, the company that owns the brand needs to ensure that this quality is consistently met. If it does not manufacture its products for itself it needs a range of suppliers to manufacture the cakes and package them accordingly. Each supplier is governed by health and safety legislation and has contractual requirements to deliver this quality product. However, the company’s reputation stands or falls on the quality of the cakes, so it cannot afford to leave this to the integrity of its manufacturer. The company therefore employs people to regularly make unannounced visits to the sites, where they walk through the production line. They check every step to ensure that quality is being adhered to.

This is the role of the PCT; we cannot leave the quality agenda to providers alone. We are guardians of the public purse and so have to assure ourselves that public money is being spent wisely and delivering the agreed level of quality as described in the contract and quality schedules. Therefore we have developed a range of processes that enable us to fulfil this role. Commissioners undertake a number of key activities, outlined below.

Clinical quality review meetings

First, a monthly clinical quality review meeting takes place, which is separate from monitoring activity, performance and financial contract. Quality review meetings are chaired by the PCT’s director of nursing or medical director, and practice based clinicians and professional executive committee (PEC) members also attend. Directors of nursing and medicine and a number of other clinical staff are expected to attend from provider trusts (including acute, mental health and community services).

The vision is that clinical colleagues will transcend organisational boundaries, discuss patient care and devise improvement methods as necessary. This may not always happen in reality, as it is extremely difficult for providers to share their concerns if it results in commissioners serving performance notices for non delivery of the requisite standard of care. For commissioners it is impossible to hear about clinical risks and patient care concerns and then assume that the provider will effectively address these issues. This tension can only be managed by building trusting relationships,where people can have the courage to own inherent risks together and develop shared solutions to ensure patient care continually improves, and if unacceptable standards of care are not tolerated by either party.

The new arrangements mean that GP consortia will have to develop their own approach to monitoring quality. However, they may well start from a strong position in that they will already have developed relationships with local clinicians, and be able to manage this risk together. It is too early to judge this.

Quality reports

PCT boards receive regular quality reports outlining the performance of all their providers. These include a wide range of information: complaints; incidents; compliments; patient and staff survey results; national audits and other benchmarks. The aim is to build a picture to enable boards to assess the quality of provision by comparing providers across the PCT region and analysing trends and in-year changes. This also provides them with early warning signs should a provider trust start to get into any difficulty.

If a trend began to appear in the type of serious incidents (SIs) occurring in a particular service then the board would ask for further information to assess the cause. By their nature SIs should be rare and isolated occurrences, so if there was a third SI in a single year relating to a similar area, event or procedure, the board would want to see the full investigation and root cause analysis of each incident and discuss this with the provider to ensure there was not a systematic failing. GP consortia will no doubt develop their own reporting and monitoring arrangements.

Reality checks

Reality checks include unannounced and announced visits to services by commissioners, talking to patients and staff to establish the quality of provision. Other measures include gaining “soft intelligence” from GPs and other service providers – this includes raising their own and their patients’ concerns. Community nurses have a wealth of information about which wards discharge well in terms of giving information to both patients and district nurses, providing enough dressings or equipment, and generally planning patients’ care. They also know when this does not happen, and are encouraged to complete incident forms so these issues can be raised at an organisational level, and dealt with accordingly.

GP consortia will have much of this information first hand, so collation should be easier – but nurses will need to ensure their views of services are heard too.

Implications for nurses

Nurses who are already in commissioning roles can clearly see the value of their role and their ability to bring the nursing perspective into this important activity. For those nurses already in commissioning posts, it may be extremely clear what their role is. However, few commissioning posts specifically require the post-holder to have a clinical qualification, which means commissioning is not yet widely seen as part of the nursing career pathway.

Many nurses have taken on commissioning roles by chance, but once in such posts they have great scope to use their nursing skills to influence commissioning outcomes. For example, developing a focus on end of life care within a commissioning organisation, and successfully using commissioning processes to secure board approval for a care strategy in this area, supported by investment and service redesign proposals, can impact on thousands of patients’ lives each year.

The disadvantage of commissioning is that it takes time and effort to achieve this scale of change, with few expressions of gratitude along the way. Commissioning may not suit those seeking the instant satisfaction of providing care to patients and seeing that the intervention has left them comfortable, pain free and grateful. However, even as a provider, commissioning is a nursing responsibility. If nurses do not understand and get involved with this process, they lose an opportunity to influence decisions and quality measures which impact directly on patients. In the Ten Key Roles for Nurses (DH, 2002), the tenth role requires nurses to take a lead role in organising local health services - this means influencing commissioners to ensure services are properly developed, planned and delivered.

Some nursing teams have developed their services over the years. For example, trials without catheter are now more common in the community than previously. For patients, having their catheter removed at home where they can use their own toilet and avoid a hospital visit must be a better experience. Nurses need training, the right equipment and the ability to make the necessary number of visits to ensure patients can cope without the catheter. For commissioners (and the public purse) this is a better quality service and unlikely to cost more. However, would they notice this one intervention among the many issues they address unless community nurses developed the proposal, and presented it to them as a business case? For the case to succeed, it needs to involve the whole PCT population, not just one or two teams. Service changes should not be based on the goodwill and enthusiasm of one or two well motivated teams but spread across the whole service.

Expertise

Nursing input in the quality schedules, CQUIN developments and service specifications are crucial. Only nurses know what quality looks like for some aspects of the patient journey. They also have local knowledge about many of the other services provided for patients and, crucially, where there are gaps.

Nurses also hear the patient and family perspective and can act as their eyes and ears. This type of “soft intelligence” is extremely valuable for commissioners, though many may not yet have developed methods to capture it.

Finally, nurses bring a unique perspective to commissioning; the following anecdote illustrates this. While travelling with a doctor friend, we witnessed a road traffic accident in which an older couple were injured. The man looked ill, grey and distressed; we focused on him, and my friend was clearly preparing for a cardiac arrest. The patient kept asking where his wife was, and though we reassured him, he continued to ask. I found his wife, assessed her mobility, and moved her so she could sit next to him. As she held his hand he visibly relaxed and regained some colour. The doctor and nurse perspectives were different but both equally important to the patient. Both are needed for commissioning.

Conclusion

Nurses are vital to commissioning and should take steps to become involved as soon as possible. They can do this by finding the right people to talk to, perhaps by spending a day with the PCT’s director of nursing or a PEC member, or by inviting themselves to observe a practice based commissioning meeting. Nurses should engage in local plans for developing GP consortia so they know who the change agents are and where to direct their energies. Then they should find out how to write and present simple business cases.

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