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?