Commissioning Community Services – The challenge

Michael Sobanja23 March 2006

User side reform

CommissioningPBC

Clinician engagement

Patient choice

Supply side reform

PluralityFoundation

TrustsCompetition

Payment systemsPBR – Contracts – C4H

RegulationMonitor NSFs – NICE-HCC

Three broad phases to NHS Reform

Central Direction

National Standards

Financial Investment

&Support

“ConstructiveDiscomfort”

"District nurses, health visitors and other staff delivering clinical services will continue to be employed by their PCT unless and until the PCT decides otherwise.“

25 October 2005

What is commissioning?

Commissioning is the process which determines how the health and the healthcare budget is used.

Meeting the needs and/or wants of local people?

At and affordable level?

From whom?

What's the evidence base?

Integrated access to health and social care services

Levels of Commissioning

National

Regional

PCT/LA

PracticePractice

LocalityLocality

NeighbourhoodNeighbourhood

ClusterCluster

PCT Associations

Who commissions Primary care?

PCT 10 20 30

CO

MM

ISS

ION

ING

PBCPBC

The real challenge?

To commission excellent services in the community that are built around the patient and to

develop and deliver effective community based approaches to keeping people healthy

THE DILEMMAS OF COMMISSIONING

Trying to improve the experience and health of the individual patient without micro-managing the providers

The trade-off between the interests of individuals and those of the wider community

Balancing national priorities with local aspirations and flexibility

Investment in health improvement (long term payback) versus investment in health services (immediate gratification)

COMMISSIONING

Different components:

Equityfair distribution of evidence-based benefits

Responsivenessemotional consequences of decisions

Efficiencyeconomic considerations including cost-effectiveness

Different groups will tend to prioritise these components as follows:

Commissionersequity, efficiency, responsiveness

Patientsresponsiveness, equity, efficiency

Providersefficiency, responsiveness, equity

EFFECTIVE COMMISSIONING

A clinical and managerial dialogue informed by patient and user views

Creating better patient/user services, pathways and experiences

A focus on improving process and outcomes - changing the fundamentals of the system

A focus on the key problems facing the health community

A focus on health economies rather than individual organisation

A new range of services

Traditional primary care services, such as district nursing, midwifery, health visiting, physiotherapy and podiatryDiagnostics and specialist outpatient services previously delivered in hospitalExpanded walk-in services that include diagnostic tests, screening, clinical advice, basic prescriptions and health promotionAdditional services, such as sexual health services, treatment for drug and substance abuse, care for asylum seekers, prison healthcare, care for ethnic minority groups, services for care homesInpatient services at a community hospital or nursing homeMental health services including community psychiatric nursing and counsellingComplementary medicine?Local health information and advocacyPharmacy, dentistry and optometry

The New Providers

Supermarket chain Sainsbury's has announcedplans to open general practitioner services in itsbranches across the country.

GP GMS/PMSPartnerships

Not for Profit

companies

Foundation trusts

Pharmacos

Voluntary

Sector

Private

Companies

Mutuals

Clinician

Chambers

DiabetesSpecialist

Nurses

Diabetologists

Receptionistsand

SupportWorkers

On CallServiceDiabetes

Specialist TeamHigh RiskFoot-care

Team

CommunityPodiatry

CommunityNurses

Vascular &Orthopaedic

Surgery

Orthotists &FootwearSpecialists

Paediatric DiabetesSpecialistNurses & Doctors

Services forYoung People

Primary CareDiabetesTeams

Primary CareDiabetesTeams

Primary CareDiabetesTeams

Primary CareDiabetesTeams

Primary CareDiabetesTeams

Primary CareDiabetesTeams

Hospital Dietetics

CommunityDietetics

EyeScreening

Optometrists

OphthalmologyLaser & Cataract

Services

SpecialistVitreo-RetinalServices Nursing

Homes

Medical WardsWards

ObstetricsJoint DiabetesAntenatal

Service

Nephrology

Cardiology

CardiacSurgery

Rheumatology

A & EEmergency

Medicine

Surgical Wards

Components ofan Integrated

DiabetesCare

Service

ClinicalPsychology

Primary & Community‘Continuing Care’

Diabetes SpecialistServices

SupportingSpecialist Services

Direct AccessServices

NHS Direct

Web Based Services

Pharmacies

Call Centres

Information Services of the National Health System - Four Elements

CONTEXT – Health Services Providerscommon descriptions and details of services and providers within the health system, their configurations and locations

INTENT – Standards for Health ServicesUsing clinical knowledge and adopting standards of care across the health system e.g. National electronic Library for Health

ACTIONS - Personal Health Managementelectronic records, e- bookings, referrals, investigations, and prescriptions

OUTCOMES - Measuring Performance of Health Servicesconsistent support of the clinical audit of individual care

Where can I go?

What will they (we) do?

What did they (we) decide?

Did it do any good?

Information for Commissioning

Understanding need and demand

Comparative performance

Capacity generation – generating a market?

Understanding the true cost base

Giving patients useful information

…

 JOINED UP THINKING !

PCS Web - a groundbreaking new e-record system that gives everyone in the primary care team instant, online access to patients' records - is being piloted in two PCTs in England from next month.

For the first time in the UK, health visitors and district nurses will have their own tailored e-nursing care records, based on the internationally recognised Omaha classification system. Staff will be able to draw up nursing care plans and make detailed assessments of social aspects such as patients’ living conditions, hygiene needs and ability to care for themselves; areas that a traditional GP system does not cover, but that are essential for other staff to plan care and measure outcomes.

Proposals are in hand to expand health services in the home.

'I don't like it. They're queuing for surgery on the kitchen table.

The public is in favour of shifting care

Key Challenges – what do you think

How do we specify community health services – particularly the “ethos”?Who do we see as the possible providers?How do we measure the volume of services?What is the outcome?How can we increase investment?How do promote inter-practice collaboration?How do we tie it together with Local Auhtority services?What part should Non Execs play in commissioning?