An outline of how one PCT embarked on a quality commissioning agenda, and how nurses can take a leading role in the process
Maggie Boyd, MPH, RHV, RM, RN, is executive director of clinical quality and nursing, Derbyshire County PCT.
Boyd M (2009) How to ensure quality is at the heart of the commissioning process. Nursing Times; 105: 44, early online publication
Quality and commissioning are now taken to be synonymous. But before the NHS Next Stage Review and world-class commissioning turned attention to quality, Derbyshire County PCT had embarked on a quality commissioning agenda of its own.
This article explains how the PCT went about putting quality on a par with finance and performance in its commissioning activities and took a strategic approach to improving quality.
Keywords: Commissioning, Quality, Primary care trusts
- This article has been double-blind peer reviewed
- Nurses have much to contribute to commissioning because they have led clinical teams and taken responsibility for quality of services, and have a wide range of experience across the care pathway.
- Setting quality standards collaboratively with providers ensures that relevant data can be provided and that they are engaged with the process.
- Quality standards should be selected from data already collected where possible.
- Using common quality standards across providers and services allows benchmarking.
Derbyshire County PCT was formed in October 2006 from the merger of six smaller PCTs: High Peak and Dales, Erewash, Derbyshire Dales and South Derbyshire, North Eastern Derbyshire, Amber Valley, and Chesterfield PCTs. The chief executive had a vision to put quality on a par with finance and performance in all the PCT’s activities, including commissioning.
Derbyshire County is the eighth largest PCT in the country, commissioning services for a population of over 711,000. Its catchment area consists of a combination of rural, urban and ex-coalmining areas around the M1. There are pockets of deprivation, mostly within the urban areas, with some rural poverty in farming communities.
The PCT is spread over a large geographical area so commissioning the right level of services locally is challenging.
Where people are required to travel to services, those living in the north of the PCT area will prefer to go to Stockport, Manchester and Sheffield, whereas those in the south will look to Nottinghamshire and Staffordshire. As a result the PCT commissions from providers across three strategic health authorities (SHAs).
What is commissioning?
Commissioning is the mechanism by which a PCT determines the services its population needs and purchases them to secure the best value for patients and taxpayers. The objective is to ensure the best possible health outcomes, including reducing health inequalities, within the budget available, ensuring good use of public money.
The millions of individual patient and clinical decisions that lead to the provision of care and commitment of resources are central to commissioning, but these are just part of a larger process (Fig 1).
The PCT may commission its own services from a provider or work with other PCTs to commission services from one provider together. When this happens one PCT will act as the commissioning lead.
As lead commissioner, the PCT is responsible for not only its own contracts and quality but those of other PCTs as well. For example, Derbyshire County PCT is the lead commissioner for the whole of the East Midlands Ambulance Service, so is responsible for commissioning services for PCTs in Lincolnshire and Leicestershire as well as for its own patients. It therefore needs to engage these PCTs and gain their views about the service they want.
Nurses in commissioning
Although nursing is not a profession often linked with commissioning, in the places where nurses are involved, such as Derbyshire County PCT, they play a valuable role.
Nurses have a deep understanding of what providing a quality service actually means. They have experience of taking a lead role in running clinical teams and in managing the quality of patient care wherever it is provided, including community settings, hospitals and nursing homes.
The value of having doctors - especially GPs -involved in commissioning is well recognised, because of their clinical expertise and extensive contact with patients. While some of what nurses can offer is similar, they have complementary expertise to medicine, often due to their broader range of experience in diverse settings.
World-class commissioning competencies focus on clinical engagement, and it is vital that nursing professions do not become marginalised in commissioning processes. Involvement of clinical leaders is essential to inform both the medical and healthcare pathway.
Derbyshire County PCT quality team has a broad range of experience and has worked in many different settings. The team therefore has more experience of seeing how a patient care pathway works well or not so well, which helps in identifying and resolving problems, and brings the lessons learnt from when services have not worked so well.
Nurses are effective executive players and corporate leads, because they are used to working in the culture of large hospitals and community teams. Box 1 outlines the team’s range of skills and experience.
Box 1. Team skills
- Ability to build rapport with patients and carers, clinical leadership and leading clinical teams
- Team work, political acumen
- Information analysis and performance management
- Investigation skills
- Ability to influence and act as patient advocate
- Facilitating across teams within the organisation
- Change and improvement skills
Box 2. Principles for clinical quality
- Consistent clinical excellence
- Improved health for all
- Outstanding patient experience
- Joined-up care pathways
- Working well with partners
- Systematic and credible reporting
Source: Derbyshire County PCT (2009)
Developing quality schedules
During Derbyshire County PCT’s first year, a lot of time was spent determining what was meant by quality, getting the right people in place to lead and develop the approach with a clear set of objectives.
A set of key defining principles on quality was developed in collaboration with the commissioning directorate, which is responsible for procurement and contracting, to encourage engagement across the whole organisation (Box 2).
During 2007-08 a commissioning framework was developed for all PCT-commissioned services, which include acute hospitals and foundation trusts, community services, mental health, primary care (general practice, dentistry and pharmacy), out of hours and prisons.
The plan was to agree quality schedules with providers to gain assurance that the health services commissioned from these providers were of an acceptable standard. Areas that required improvement could then be identified early and action taken to drive up quality through the procurement and development. The approach was to adopt a culture of continuous service improvement.
In what was a bold step for the PCT board, it decided that the schedules would be developed in negotiation with providers and performance assessed by a committee with representatives from both organisations.
Setting standards collaboratively with providers helps ensure that relevant data can be produced to support the standard and that they are engaged with the process. Every year the standards are revisited to be revised and updated, more recently through Commissioning for Quality and Innovation (CQUIN) (Department of Health, 2008a).
The schedules developed assess quality performance in four domains (Maxwell, 1984) (Fig 2). Each incorporates quality measures, including infections (number of MRSA and C. difficile infections), surveys or questionnaires, number of deaths, number of serious incidents and patient-reported outcome measures.
Choosing the right standards is important. There is a lot of data available, but only by selecting the right data to analyse will it be possible to judge the provider legitimately and provide assurance to the PCT board and ultimately the SHA.
In the early stages, the PCT looked externally to see how BUPA and other independent healthcare companies assessed quality. It concluded that, even though it had a legitimate role to ask about quality, it was important not to add to providers’ bureaucracy, so the focus has been on using information already collected where possible, such as data on healthcare standards, healthcare-associated infections and incident reporting. However, extra information is requested where necessary, and reviewed on an as-needed basis.
Providers are required to present evidence to show that each of the standards in the schedule is being met, which is reviewed by the joint committee. A quality score is produced summarising performance in each domain, so the provider and PCT know whether performance is acceptable or whether further improvement is required.
The approach varies slightly for different contracts to reflect different providers, services and specific circumstances. The preferred model is to have a supporting quality monitoring group involving clinicians, but quality of care and patient safety will always be discussed within the contract management board or quality group. A partnership approach has been essential as sometimes there is “nervousness” about sharing information and why the PCT needs it.
Quality schedules were first implemented in community services. At that time the PCT was the provider of community services, but now that function has been developed into an arms-length service called Derbyshire Community Health Services. Community services were selected to pioneer the approach because it meant the PCT was able to look in depth at what the experience had been like on both sides – as a commissioner and provider.
At the end of the first year it was challenging, as the community services had been unable to provide the necessary evidence to demonstrate the quality standards in the schedule they had signed up to. This was because they did not have adequate systems from which to access the information, which demonstrated the importance of not being too ambitious initially. The best approach is to focus on a set of key objectives, such as infection control, and then build and expand on that.
It was an important learning exercise which enabled the PCT to test out its methodology, relationship building and communication strategies both internally and across the health communities involved before introducing quality schedules to other providers.
Quality schedules were next rolled out to the Derbyshire Mental Health Services Trust and Chesterfield Royal Hospital Foundation Trust, and now the learning and development has supported the approach for all services the PCT commissions.
The approach enables the PCT to focus on issues it wants to prioritise, such as infection control. As lead commissioner for ambulance services across the East Midlands, Derbyshire County PCT was particularly keen to instil a culture of continuous quality improvement, and financial incentives have been included in the quality schedule. These incentives cover areas such as cannulation and other infection control best practices.
The quality schedules were extended to foundation trusts, which enjoy greater freedoms than other trusts and are regulated by Monitor, the independent regulator. These trusts very much wanted to be in the driving seat, so the PCT had to make it clear that, in terms of quality of locally commissioned services, it was setting the agenda. PCTs have a clear responsibility to ask about the quality of services provided, so confidence had to be acquired to take the lead in the relationship.
Over the last few years the PCT’s relationships with foundation trusts have improved and strengthened, despite some difficult negotiations. The relationships are much more mature and work is now underway on continuous improvement in care pathways.
As well as commissioning services with other PCTs, the PCT commissions some services in conjunction with other organisations, such as respite care with the voluntary sector and care homes with the local authority.
Improving quality in care homes, which are independent, has been difficult. However, since April 2009 the Care Quality Commission has been responsible for regulating both health and social care and supports driving up standards and quality in the care sector.
The commissioning is in partnership with the local authority, ensuring patient care and safety issues are high on the agenda has been difficult. Nurses act as advocates for patients and they find the urgency with which social care considers issues frustrating. The PCT board considers this area as a high priority as the organisation moves forward.
Derbyshire County PCT put in place a quality schedule with indicators such as pressure sores, nutrition, falls and infection control, and this has already led to some improvement. Where problems have been identified, the PCT has mobilised resources and given extra support to help resolve them.
Numerous GP practices provide primary care services, so a balanced scorecard is used to collect quality information. The PCT has implemented annual clinical governance visits to help collect the necessary data. These are conducted in a structured way, so that they are also developmental for practices.
The next step is to extend the range of information collected, and to present the results to the PCT board.
Quality schedules for this financial year (2009-10) have been based on learning from last year and national contracts.
For the first time this year a proportion of providers’ income (0.5% of their contract’s worth) has been made conditional on meeting locally agreed quality and innovation goals under the national Commissioning for Quality and Innovation (CQUIN) payment framework (DH, 2008a). It is expected that in the future this proportion will rise.
As we look towards the next contracting round of 2010-11, the systems and processes are more mature and we will be setting more ambitious goals.
Gathering comparable information for different contracts and providers to enable the PCT to benchmark performance has been a challenge across the whole health community.; For example, this is difficult in acute services where the PCT commissions from seven different trusts. Such data would also enable trends in common issues, such as falls, to be tracked and dealt with more effectively across different health sectors.
Quality is an essential component of commissioning. Poor quality services are not value for money because patient experience is low and complications and adverse events will need to be rectified where they occur.
Quality improvement is therefore something commissioners should always strive for. This requires a strategic approach where quality is central to the commissioning process and assurance systems are built into the process right from the start.
Where a strategic approach is not taken, commissioning organisations will merely be fire fighting – that is, only picking up issues and tackling them when something goes wrong. A strategic view on all aspects of quality will ensure continual improvement so there are fewer mistakes, and that patients receive the best possible care and best value for money.
Nursing has much to offer to the commissioning process. Developing the next group of leaders is essential to make sure patient care and quality remain central to health policy.
- Commissioning is the process by which PCTs ensure the best possible health outcomes for their populations, including reducing health inequalities, within the budget available.
- The NHS Next State Review (DH, 2008b) focused the NHS’ attention on quality. Quality is about: protecting patient safety by eradicating healthcare-associated infections and avoidable accidents; effectiveness of care, from the clinical procedure to patients’ quality of life after treatment; and patients’ entire experience of the NHS to ensure they are treated with dignity and respect.
- The national Commissioning for Quality and Innovation (CQUIN) payment framework (DH, 2008a) enables a proportion of the provider’s income to be conditional on meeting agreed quality standards.
Department of Health (2008a) Using the Commissioning for Quality and Innovation (CQUIN) Payment Framework. London: DH.
Department of Health (2008b) High Quality Care for All: NHS Next Stage Review Final Report. London: DH.
Department of Health (2006) Health Reform in England: Update and Commissioning Framework. Annex: The Commissioning Framework. London: DH.
Derbyshire County PCT (2009) Annual Clinical Quality Report 2008/09. Chesterfield: Derbyshire County PCT.
Maxwell RJ (1984) Quality assessment in health. BMJ (Clin Res Ed); 288: 6428, 1470–1472.