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Service design and commissioning is a complex process

Dr Shane Gordon explains that commissioners will need to take into account a broad range of legislation, guidance, information, and data when commissioning services

The essence of good commissioning is the securing of the best possible services for the local population using the available resources. This requires a wide range of knowledge and the juggling of often competing priorities. This article reviews the considerations that commissioners must take into account in their planning, and the sources of information which they might use in doing this.

Improving outcomes

The NHS Constitution, which became a legal obligation in 2009, states that the purpose of the NHS is to, ‘... improve our health and wellbeing, supporting us to keep mentally and physically well, to get better when we are ill and, when we cannot fully recover, to stay as well as we can to the end of our lives.’ 1

The NHS Mandate, published in November 2012, notes that, ‘... public expectations of good healthcare do not stand still’;2 the benchmarks for measuring good care are constantly rising. International comparisons of population-level outcomes can be used to reflect on how well the NHS achieves its purpose. These comparisons suggest that in some aspects the population of England does not have equivalent health outcomes to other developed countries; for example, life expectancy is higher in many developed countries, such as Japan, Spain, and Italy, whose per-capita spend on health is lower than Great Britain.3 Cancer survival in the UK also lags behind many other developed nations, including Australia, Canada, and Sweden.4

National versus local perspectives

A comparison of health outcomes at a local level reveals a vast amount of variation from the national average. This variation applies to almost any imaginable measure. For example, mortality from coronary heart disease in people aged under 75 years has an almost three-fold variation across England.5 If you need convincing, browse through the excellent NHS Atlas of Variation (), which maps variation at a local level on dozens of outcomes. This variation means that local commissioners often want to prioritise services to meet local needs. These local priorities may be subtly (or even widely) different from the priorities observed from a national level, which average out this local variation. In recent years the Government, through the Department of Health (DH), has tried to align the priorities of local commissioners with the national priorities, by setting targets for improvements in particular processes (e.g. waiting times for cancer treatment) and through development of national ‘best practice’ guidance such as NICE guidelines or National Service Frameworks.

A new approach is required in line with the Health and Social Care Act6 under which the DH will no longer set specific targets for treatments; instead, the NHS Outcomes Framework specifies the national outcomes for the NHS. Within this framework, Outcomes Indicators are identified at clinical commissioning group (CCG) level.7 The Secretary of State now sets an NHS Mandate2 for the NHS Commissioning Board (NHSCB) detailing the required improvements in outcomes and service standards. Basic standards are embedded in the NHS Constitution,1 including waiting times for cancer and routine treatments. Figure 1 shows how NHS standards, outcomes metrics, and planning guidance flows through the new NHS structures.

Figure 1: Flow of outcomes, standards, and planning guidance in the new NHS structures

CCG=clinical commissioning group

Service design and commissioning is a complex process continued

NHS Outcomes Framework

The NHS Outcomes Framework is developed by the NHSCB and takes into account NICE quality standards,8 which describe current best practice in medical care.9 It has five domains that encompass quality of care in terms of:9,10

  • effectiveness
  • patient experience
  • safety.

Figure 2 shows how the five domains relate to these outcomes. There are similar and complementary outcomes frameworks for public health10 and social care services,11 and their outcomes data are updated regularly on the NHS Information Centre website.12

Figure 2: The five domains of the NHS Outcomes Framework9,10

Reproduced with kind permission from the NHS Commissioning Board

NHS Mandate

The new NHS Mandate is designed to ensure that, ‘... Ministers are more transparent about their objectives while giving local healthcare professionals independence over how to meet them … [and] to provide the NHS with much greater stability to plan ahead.’2 It requires progress against all five domains of the NHS Outcomes Framework, and an annual assessment of the NHSCB performance. The NHS Mandate for 2013 to 2015 identifies five areas of priority for progress in the NHS:2

  • improving standards of care and not just treatment, especially for older people and at the end of people’s lives
  • the diagnosis, treatment, and care of people with dementia
  • supporting people with multiple long-term physical and mental health conditions, particularly by embracing opportunities created by technology, and delivering a service that values mental and physical health equally
  • preventing premature deaths from the biggest killers
  • furthering economic growth, including supporting people with health conditions to remain in, or find work.

CCG Outcomes Indicator Set

Clinical commissioning groups are responsible for outcomes in their local health systems. For each CCG, a set of localised indicators will be identified, drawn from the NHS Outcomes Framework—the Clinical Commissioning Group Outcomes Indicator Set (formerly known as the Commissioning Outcomes Framework). In setting their strategic goals, CCGs will be required to set themselves aspirational improvement targets against their local indicators, which may be opened to challenge if the NHSCB believes they are not ambitious enough.


Service design and commissioning is a complex process continued

NHS Constitution

The NHS Constitution sets out the rights of patients in NHS services and these include the rights to:1

  • timely treatment (waiting times for routine and cancer treatment)
  • treatment with dignity (single-sex accommodation)
  • choice of treatments including choice of hospital for elective surgery.

Role of commissioners

The duty of commissioners to secure the best outcomes for the population they serve, within the resources available to them, is sometimes described as ‘value’,13 which equals health outcomes ÷ cost. This value is particularly important where there are inequalities in health outcomes. These may arise due to deprivation and social or demographic characteristics. In the current financial climate, where the rising costs of healthcare are likely to exceed the increases in funding for the foreseeable future, commissioners must strive ever harder to increase the value of health services. To achieve this, they will need to find common ground with other commissioners of public services, particularly social care.

The commissioning process

To improve the value of health services, commissioners must first identify the health needs of their population, which will allow them to prioritise their investment to reduce inequalities and maximise the gain in value. Contracts for commissioned services must be monitored to ensure that the outcomes and success expected for that investment are reviewed regularly in order to continually improve the process—this forms the ‘commissioning cycle’ (see Figure 3). Public involvement in planning and evaluation is crucial to ensuring a responsive service.

The effective planning and monitoring of health services requires information and data that is timely, accurate, meaningful, relevant, recognisable, and reconcilable with other data (see Table 1). Joint Strategic Needs Assessments provide a broad review of healthcare and social care needs, including burdens of disease, local activity data, and inequalities in outcomes, and are an important resource for commissioners.14 These assessments are led by public health teams, which are now embedded in local government.

Clinical commissioning groups are required to align their approach with the priorities for commissioning in local joint health and wellbeing strategies, which are set out by local health and wellbeing boards, hosted by local government, and include healthcare and social care commissioners.

Benchmarking data is essential to assessing the relative success of local commissioning, while activity data allows the ongoing monitoring of performance.

In addition to commissioning services to meet the needs of their population, commissioners must also ensure that these services are safe and appropriate. This includes ensuring appropriate clinical governance (such as processes to manage serious incidents) and the safeguarding of vulnerable children and adults.

Commissioning is a complex task involving competing priorities and a wide variety of views. The learning curve is very steep and many clinicians are surprised by how long it takes to achieve changes. Learning patience and acknowledging that this is a new domain of learning are important for avoiding frustration.


Service design and commissioning is a complex process continued

Figure 3: The commissioning cycle

Copyright © 2013, re-used with the permission of The Health and Social Care Information Centre. All rights reserved.
Table 1: Information and data that commissioners will find useful
Purpose Information types and sources
Planning
  • Clinical Commissioning Group Outcomes Indicator Set
  • Joint Strategic Needs Assessment.
Benchmarking
  • NHS Comparators (The Information Centre, see: )
  • Commercial products (e.g. Dr Foster)
  • Mortality measures: hospital standardised mortality ratio and summary hospital-level mortality indicators
  • National Patient Experience survey (Care Quality Commission)
  • Patient-Reported Outcomes Measures (The Information Centre, see:
    )
Activity monitoring
  • Accident and emergency, outpatient, elective, and inpatient data,
    re-admissions (NHS Secondary Uses Service)
  • Ambulance data
  • Rights as outlined in the NHS Constitution.

Service design and commissioning is a complex process continued

Conclusion

Commissioning of the NHS must continue to focus on delivering the best value services for local populations and reducing inequalities in health outcomes. The continuing financial pressures mean that the rate of productivity and quality improvement needs to increase so that services can continue to meet the public’s high expectations. Commissioning is as much art as science, but both managerial expertise and clinical leadership are required to be successful.

Key points
  • Health outcomes are continually improving and UK health outcomes must be viewed in an international context
  • There is significant local variation in health outcomes
  • Commissioners must seek to secure the best value from NHS services for their population and to reduce inequalities in outcomes
  • The NHS Outcomes Framework and the NHS Mandate set a new framework for commissioning
  • The NHS Constitution sets out the rights of the public to expect minimum standards of quality and patient experience from NHS services
  • Local priorities need to be set within the context of the Joint Health and Wellbeing Plan and developed with local government partners
  • The commissioning cycle describes the continual cycle of planning and evaluation in commissioning health services
  • Commissioners will require multiple sources of information to make decisions.

References

  1. NHS. NHS Constitution. London: NHS, 2012. Available at:
  2. Department of Health. The mandate. A mandate from the Government to the NHS Commissioning Board: April 2013 to March 2015. London: DH, 2012. Available at:
  3. Organisation for Economic Co-operation and Development. Health care systems: getting more value for money. OECD economics department policy notes, No. 2. OECD, 2010.
  4. Coleman M, Forman D, Bryant H et al. Cancer survival in Australia, Canada, Denmark, Norway, Sweden, and the UK, 1995–2007 (the International Cancer Benchmarking Partnership): an analysis of population-based cancer registry data. Lancet 2011; 377 (9760): 127–138.
  5. NHS Right Care 2010. NHS atlas of variation in healthcare. Reducing unwarranted variation
    to increase value and improve quality.     London: NHS Right Care, 2010.
  6. Legislation.gov.uk website. Health and Social Care Act 2012. www.legislation.gov.uk/ukpga/2012/7/contents/enacted (accessed 1 February 2013).
  7. NHS Information Centre for Health and Social Care. CCG indicators—December 2012 release.
  8. National Institute for Health and Care Excellence website. NICE quality standards topic library. www.nice.org.uk/guidance/qualitystandards/QualityStandardsLibrary.jsp (accessed 30 January 2013).
  9. NHS Commissioning Board. Everyone counts: planning for patients 2013/14. London: NHS Commissioning Board, 2012. Available at:
  10. Department of Health. NHS outcomes framework 2012/13. London: DH, 2012. Available at:
  11. Department of Health. The adult social care outcomes framework 2013/14. London: DH, 2012. Available at:
  12. NHS Information Centre for Health and Social Care website. (accessed 30 January 2013).
  13. Porter M. Value-based healthcare delivery. Presented at Harvard Business School healthcare initiative: March 7, 2012: Harvard, MA.
  14. Department of Health. Guidance on joint strategic needs assessment. London: DH, 2007. Available at: G

Dr Shane Gordon

GP and Chief Officer,
NE Essex Clinical Commissioning Group

Leadership group member
NHS Clinical Commissioners

View the eGuidelines.co.uk hub on commissioning at: eguidelines.co.uk/hub/commissioning

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