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Thoughts and opinion from the wards
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Clinically led commissioning - Starter for Five
Clinically led commissioning is just what it says; clinicians leading the process of determining what care is needed and then purchasing those services for the local population. For many this is a new direction and there is a great deal of enthusiasm and a real passion to get on and just do it.
In these hectic times how do we focus on those important issues that will deliver the “holy triad” of improved quality, cost effectiveness and patient satisfaction?The most logical approach is to focus on those clinical areas that we just know could be commissioned and delivered so much more effectively such as urgent care, ambulatory conditions; (such as cellulitis, heart failure, asthma), end of life care, primary and secondary prevention etc and here I refer you to the excellent recent publication from the Kings Fund “Transforming our health care system “Ten Priorities for Commissioners” http://www.kingsfund.org.uk/publications/articles/transforming_our.html However; important as these are let’s just step back and ask ourselves why is it just so difficult to spread best practice form one location to another? This is the area I think consortia need to focus on, as if we understand this and get this right we can develop the foundations of effective commissioning bodies. The priority areas for focus in order to develop a secure commissioning foundation are; - quality in primary care, population based approach to health, systematic and proactive approach to long term conditions, integration of services and developing an healthy organisations. These are not simple chapters in a book you can take down from a shelf and go off and implement, they are values and behaviours; they are a way of thinking that needs to be transcribed into every fibre of the developing consortia’s structure; as its only when they are held as beliefs and values that the organisation will be effective in how it approaches clinical change. Starting with primary care currently we have largely groups of independent practitioners working within the NHS to meet the health needs of their patients. We need to develop from this to a synergistic group of practices working collectively together in a collective "corpracy”; these are in effect Federations. A Federation is more than the sum of its parts and the RCGP have done lots of good work on this. If we now look at the need for a population based approach you can see how this works within a Federation; focusing on the whole population and moving away from simply the patient in front of you. Several groups such as Tower Hamlets have made striking improvements in the health of their populations by adopting this holistic approach and releasing the power of primary care. The next foundation principle is about having a proactive and systematic approach to the management of long-term conditions. Is this a value or just another action? The words systematic and proactive make this a clear value; a way that you approach the commissioning of care in the consortia. Starting with stratification tools to identify those at risk and then supporting them in their homes, moving to a comprehensive system to " pull" patients out of hospital and also manage patients in nursing and residential homes. Such approaches are fundamental to managing the significant challenges arising from our ageing population. Integration of care is one of those concepts that everyone agrees on but few can actually implement. Once more this is also value moving from the “Them and Us” position to the “We” position. We have many different "tribes" in the NHS and there is an absolute need for us to collaborate in health care delivery. One example being the implementation of referral management systems. These work effectively when primary and secondary care agree the pathway jointly; then they hold their members to account to use it rather than unilaterally developing a pathway. Finally there is a wealth of evidence to show that developing "healthy organisations " leads to improved performance. “Healthy” organisations are those that have a clear sense of direction, shared values, clear culture, hold each other to account, are innovative, externally facing, build the right capabilities and are learning organistaions.The evidence is clear is that if you build your organisation upon these foundations you have a much higher chance of success. Consortia are just developing: the above values and behaviours will provide a strong foundation for them to rise to the challenges that lie ahead. These will enable them to successful implement the changes that are required to achieve the improvements we seek in patient experience, cost effectiveness and quality of care. What will happen to my salary? GP remuneration through GMS and PMS contracts has not been significantly changed to reflect the new commissioning roles of GPs.At the moment there is no nationally agreed rate for the involvement of GPs in management and leadership roles. In the transition to when Consortia go live each PCT has an a fund of £2 per patient to support GPs in the development of consortia. The lead roles in consortia such as accountable officer will have clear job descriptions, selection processes and remuneration: other roles supporting consortia are likely to have their remuneration determined following decisions of the governing body of the consortia. Can I get fired from a consortium? It is good practice that those in management roles have clear job descriptions and objectives and that they are assessed against these. Those who have difficulty in achieving their objectives are offered support and development and reviewed to see if their development needs are being metIt is rare that repeated performance failures lead to an individual being sacked however these will be decision for each Consortia team.It is very unlikely that individual GPs not in a management role will be asked to leave a consortia. The only likely possibility being if their performance was consistently poor despite all attempts from the consortia to support the GPs to improve and that this was detrimental to the health of the local population Can I still refer patients if I'm not on the commissioning board? All Gps in a consortia are advocates for their patients and able to refer those patients in the most appropriate way to meet their health needs. Many consortia are developing agreed referral pathways with secondary care that provide the best quality and are the most cost effective. It is likely that consortia will work with GPs to achieve agreement on referral pathways. Who will monitor consortia GPs? The National Commissioning Board will be responsible for commissioning Primary Care. However it is likely that local Consortia leaders will play a significant part in helping to ensure that the provision of primary care is of the highest quality. In particular they are likely to work closely with GPs on areas such as prescribing and referral management where we know there is marked variation and marked variability in appropriateness. Is there any way GPs can dip their toes in the water without being heavily involved?It is likely that there will be 3 to 4 GP leaders who spent 2-3 days per week on commissioning work in a moderate to large a sized consortia. One GP in each practice is likely to spend a half-day a week on commissioning work connecting in to the central team. Most GPs are unlikely to have to have a significant time commitment other than to be involved in discussions about how local services can be improved and also to discuss clinical audits and audits on referral and prescribing.
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