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“2020health is an important and thoughtful contributor to the health debate”

Dr Sarah Wollaston MP, Chairman, Health Select Committee

 
 

2020health Roundtable Involvement of Healthcare Professionals in commissioning with Dr James Kingsland

Sep 08. till Sep 08.

The future involvement of Healthcare Professionals (HCPs) in commissioning

A 2020health roundtable discussion with Dr James Kingsland.

Date
September 8, 20102010-09-08T08:30:00 - September 8, 2010 2010-09-08T10:00:00
Time
8:30 AM 2010-09-08T08:30:00 - 10:00 AM 2010-09-08T10:00:00
Location
Church House, Westminster

These are the summary notes of a discussion that took place on 8th September 2010. We will be exploring further HCPs involvement in commissioning throughout 2011.

The objectives of the roundtable were:

  • To discuss the recent White Paper and current consultations.
  • To discuss the involvement in commissioning of healthcare practitioners (HCPs) other than GPs.
  • To raise the key issues surrounding their involvement.
  • To compile a short report on the discussion and circulate it to politicians and DH leads.

Attendees

  1. Dr James Kingsland, DH and NAPC
  2. Karen Acott , Wallingbrook Health Group
  3. Julia Manning, 2020health
  4. Karen Middleton, DH
  5. Dawn Smith,  DH
  6. Ash Soni, NHS Lambeth
  7. Stephen Foster,  Pierremont Pharmacy
  8. Sally Gainsbury, Health Services Journal
  9. Rob Darracott,, Company Chemists Association
  10. David Craig, AOP
  11. Mark Hill, Novartis
  12. Ursula Gallagher, Ealing PCT
  13. Pamela Chesters, Mayoral Advisor Health and Youth Opportunities
  14. Susan McNulty Editor, Practical Commissioning
  15. Julian Patterson, NHS Networks
  16. Prof Hilary Thomas, KPMG
  17. Emma Hill, 2020Health
  18. Paul Hitchcock, Allied Health Professionals Federation
  19. Gail Beer, 2020health
  20. Dr Jonathan Shapiro, University of Birmingham and 2020health

 

Event Summary

Summary

 

·         Focus – if consortia see themselves as providers first and foremost then they won’t be able to get a grip on cost-containment in the cute sector through commissioning.

·         The ‘Function’ and the ‘People’ need to be decoupled so the purpose and roles of consortia can be clarified.

·         Wider role and contribution of HCPs needs to be valued; both individually -they and their representatives need to demonstrate their competencies. The centre needs to support and champion the competencies of HCPs which is pivotal to the support of the commissioning agenda. Process of accreditation should be developed for Consortia.

·         Analysis of workload should lead to recognition of what HCPs can deliver.

·         Value of wider perspective and holistic approach to care is important, getting away from a purely medical model.

·         Transparency of data to show quality crucial for local authorities.

·         Partnership – is a balance between contract (purely legal) and relationships (rapport).

·         Why, how and what all need to be understood by GP Commissioners

·         As contracts are renegotiated, there must be a level playing field between competing potential providers.

·         Accountability for governance and delivery.

·         Conflicts of interest could be avoided by a public tendering process judged by non-providers.

 

Opening remarks

 

There has been a consistent need to adopt new policy; focus always doing job i.e. delivery care around the registered list. There is a need for a whole range of HCP’s not just GPs.

Recognising when needs of population is better served by a nurse or other HCP key for GPs. GP commissioning is unfortunately named as PbC implied a multidisciplinary approach – with just ‘GP’ has this all gone. But necessary to move to being clinician-led in order to improve demand management and point of access.

GP commissioning refocuses practice, e.g. keen to know what happened to patients out of hours but currently have no control over it. What is the solution for broad spectrum community services and primary care contractors who commit resources? Two issues:

 1. GP commissioning is returning to demand management that is was always supposed to deliver and that it does this through a registered list. Not geographic population or boundaries. It’s unclear how this will work with HCPs.

2. Focus on GP commissioning, HCPS are not about commissioning but provision. Extending provision rather than being involved in analysis of the needs of that population is the opportunity here. However there is uncertainty around the evolution of primary care contracts and alignment between GPs and other HCPs without registered lists.

‘How’ is the very practical but the ‘what we do’ bit needs to have a ‘why’.  We are still using the same word (commissioning) for different functions which is unhelpful – it needs clarification. GP commissioning fits where? GPs have the best experience for procuring services for individual patients. There is also an anthropological side of involvement - spending others money is very different to your own money. Real budgets will engender some sense of perception of control and ownership. But it also needs to go beyond the ‘spend’ – it’s about feeling involved.

There are different commissioning/delivery levels. Not everyone is going to involved in every level. There are questions about the health commissioning board - can it really be spread over say Manchester and London – surely there will need to be some regional arm.

Accountability is an issue. Funnelling the resource and the control through the consortia will require clear lines of responsibility and liability. Alignment is another issue- (Q for JS: did you mean physical / geographical or incentives & accountability?

We have been through Health Authorities to PCGs to GP fund holding to PMS, APMS contracts etc. Mentality of budgets being locked in around specific groups of people is unhelpful. Services need streamlining and follow evidence based care pathways with specific outcomes.

Form does follow function and this needs to apply to GP Commissioning. Identify the function before creating the form.

Public health and self-care should be given more resources. Nanny state mentality i.e. ‘it is not my problem’ and absolute dependency on professionals is unsustainable - there is a need for changing this culture.

 Efficiencies within health will need to be supported by the wider community where HCPs are engaged with  social care – and closer alignment of health and social care should facilitate this. Engaging HCP and Social care professionals is a way of providing sustainable care in the community, de focussing from GP providers.

Themes

Team approach

 People have different roles and there are examples of different schemes – we mustn’t fall into ‘who knows best’ mentality.

Multi-professional approach. GP have traditionally been a cottage industry and turning it into a mechanism, that meets care and equality needs, is difficult.

The way through this is not through a medical model – but a more holistic approach.

Partnering with LA’s – they will want to see transparency of data so they can understand the quality differential.

It is not best to manage data through the people who cost the highest amounts!

GPs complain about time. Why not commission another GP?

Conflicts of interest

There is a ‘conflicts of interest’ conversation to be had. Need to recognise changing context.

Separating functions such as ‘make’ (provide) or ‘buy’ (procure) are important for GPs who are reluctant to get involved and those who are concerned about conflicts of interest.

However an open competitive tendering process consisting of non- providers and patients who score each competitor with the final score determines who is awarded the contract could be one mechanism. Patient involvement in tendering processes can help reduce ‘conflicts of interest’.

Economies of scale

Risk of loss of economies of scale and efficient opportunities for working if consortia too small.

Pro-active / prevention

Service users need to access services though they don’t have a medical condition. Raise issues which address inequalities early.

GPs are not going to deliver prevention – it’s too expensive. But they know the need to manage patients earlier in the pathway – not when they suddenly need acute services. Preventative and pro-active care needs to be given thought within commissioning systems, consider patient journeys.

Knowledge and De-commissioning

What are going to be the trusted sources of information about quality of care? National database needs to be agreed around outcomes in order to describe poor performers.

Clarity needed around de-commissioning poor quality providers

Learning from the past

Variability of QUOF data - opportunity to go to PbCs and ask what they have done to tackle this. Mental health collaborative – enabled the shift of 1000 people with MH issues from acute to primary setting.

Patients tend to get stuck in systems - a much more fluid pathway through inclusion of HCPs is possible.

Clinicians are very used to working with a lack of clarity. Is this a good thing? Targeted interventions are more cost effective, however clinicians are better able to manage clinical/ health risks. ‘Wait and see’ approaches have validity to a degree to ensure resources are not wasted too early.

Budget

Tactically have to keep GMS separate.

Nature of GP incentives and remuneration is a very different conversation from getting the money to the right place to provide better care.

Penalties should be considered. Creating a premium price for good quality services and understanding what these look like; setting outcomes that monitor care. Resources need to be directed the right way and if outcomes are not delivered then there should be a penalty.

Messaging

A worry of the name ‘GP Commissioning’ and its exclusive nature. There needs to be a stronger message about the other HCPs about the alternatives of provision.

Not what GP knows but what they know they don’t know. More a worry what they don’t know they don’t know. This will most affect marginalised groups – and often the professions working with these and not working within the medical model are the other HCPs. There should be a move from medical models of care to a more social one, HCPs can often provide non medical solutions to care especially when liaising with other agencies e.g. education, social care.

Requires a strong central message on the value of the contribution these can make – also from the HCPs themselves – especially on ‘what’ they can do.

Boundaries

Will there be a conundrum that PCTs working with LA’s, GPs working with lists, some HCPs working with lists, other working without? There are already examples of PbC commissioned services from e.g. pharmacy; the main issue is having a funding / reimbursement mechanism in place. Payment by results could engineer a more cohesive structure that cross boundaries.  Funding flows should require a new kind of list register common to all providers, this should mean that the patient journey can be followed, tracked and monitored. As a result any provider can be remunerated accordingly.

Unmet need

Big gap where services are available and where the need is. Known at a national level, but not reaching the coalface. This information need to be publicly available and shared in order to ensure that the equity agenda is met.

Specialist services

It would be deeply uncomfortable with a GP in control of a population of 100,000 commissioning for rare cancers. Fine for common cancers, care in the community services such as chemotherapy and end of life services.

When you get into the rare medical and technical end it’s expensive and there needs to be a national model.

Public Health

Integration with Public Health is crucial and it must inform planning.