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Achieving sustainable commissioning

Guy Gross's perspective on what works best

Wednesday, August 10, 2016

  • Guy gives a personal account of the challenges he faced as Innovation Delivery Lead at the AHSN for NW London 
  • He describes the economic impact of delivering best practice, and what he thinks success through more integrated care looks like for patients and practitioners

Hi Guy, welcome to Respiratory Futures.

Let's kick off by looking at commissioning. Your collaboration with eight London CCGs must have presented considerable insights into both their specific issues and also challenges faced more widely. In your view, what are these common issues?

The best place to start is by understanding the environment we are dealing with. Most CCGs have similar setups, reviewing their 60+ clinical pathways on a 3-year rotating review cycle. Most CCGs have different priorities for their populations with cycles that are synched differently which can make collaboration difficult.

Each pathway review assesses how care is being delivered against the latest NICE guidance and is managed by a team, usually including a GP clinical lead, commissioner, project manager, and external specialist clinical advisors. There are increasing pressures for CCGs to become more ambitious, collaborative, and to evolve pathways that deliver more value by empowering patients, embedding digital solutions and reaching more isolated and diverse cohorts of patients. Achieving this requires consideration of opportunities for innovation, embedding of best practice, moving care closer to patients, and improving outcomes in general. 

The commissioner-provider set up in healthcare has resulted in a very defensive environment. No-one wants to be seen to fail
Guy Gross

Unfortunately many of these options are passed over. This is not because the team doesn’t have an appetite to innovate. It’s because of the difficulty of scouting for and choosing relevant and implementable solutions at the time they need to be considered amid the noise of hundreds of technologies and thousands of pieces of guidance on best practice and case studies. In the end it is often perceived easier to focus on improving services by adding on new components than to be “distracted” by introducing innovations within existing ones.

This approach is problematic. It results in each CCG developing its own pathway which results in significant diversity in outcomes, standards of care and availability of services. It means the scale-benefits of collaborative commissioning are missed and ambition is limited because of trying to sustain a historic service when a total overhaul may provide better value.

These days the NHS talks a lot about ‘value’. Is there really any difference between “commissioning”, “procurement”, “purchasing” and “payment”? 

Value is a lot more than a simple equation about outcomes and cost; it is about the physical health and sense of wellbeing achieved at a price. High value in health care means getting the right care at the right time to the right patient for the right price.

The commissioner-provider set up in healthcare has resulted in a very defensive environment. No-one wants to be seen to fail which is reflected in how we build business cases and appraise investments. The lack of risk, appetite and a focus on in-year savings has driven even the best CCGs further into deficit and limited realisation of significant value.

Most of the entities listed don’t look at the whole picture; they have limitations on these views because their short-term drivers are cost-focussed and specific to their functions. As such they have incomplete and sometimes contradictory views on value which is proving costly. We have moved away from doing the right thing because it seems to be the right thing to do, to a much more restrictive system that crushes ambition and penalises brave and entrepreneurially spirited value creators.

Do these definitions impact on the day-to-day work of healthcare practitioners?  In other words, if you’re running a busy clinic does it really make a difference to how you treat your patients and, if so, how?

Firstly let’s look at the impact of activity based payment (instantly and easily deliverable) over outcome based payments (harder to assess and take time to be realised) in the context of a conversation between a GP and a patient for referral to pulmonary rehabilitation.

Under activity payments, the GP will explain the basics of rehab, make the referral, and send the patient on their way. These patients can be expected to have a high DNA rate, low compliance rate, and low completion rate because there is low understanding of benefit from the patient or incentive for the clinician to explain the importance of completing the course.

Value is a lot more than a simple equation about outcomes and cost
Guy Gross

Where GPs are paid based on a patient completing pulmonary rehab there is a very different conversation required to get the patient to attend, participate and complete. The GP will discuss what to expect, the benefits of rehab, and the impact on long-term health. No extra money needed but, with an activated patient, the desired outcome and longer-term benefits are more readily achieved. 

That leads on to the introduction of Patient Activation Measures (PAMs). Once we understand each patient’s level of engagement and literacy we can adjust the conversation with them on an individual basis to realise the most value from the limited time we have together. The most informed patients are much more likely to be proactive about their wellbeing and participate in their care than those at the other end of the spectrum. i.e. for a patient at the lower end of the scale the clinician may focus on the single most important intervention throughout the conversation rather than explain the 5 things they really ought to be doing.

Ultimately, what impact does the delivery of best practice have on the economy?

Best practice at scale will reduce variation, raise minimum levels of care, and deliver better outcomes. It is estimated that more than 10-20% of the NHS budget could be saved if the best of best practices delivered in pockets around the country were scaled across the NHS.

Our work in North-west London assessed that around 20-25% of costs in COPD could be saved simply by delivering the 2 most impactful elements of the NICE guidance consistently across the patch. The contentious points we had to overcome were investment needs, commitment to move delivery of care into the community and the timeline to realisation of the some of the benefit.

Tell us more about the programmes you developed through Imperial College Health Partners to reduce unnecessary variation in the management of COPD. Were primary and community care quick to engage more closely with their colleagues in acute trusts to raise minimum levels of care and improve outcomes? 

ICHP is the Academic Health Science Network (AHSN) for north west London, responsible for supporting the rollout of best practice and innovation across a partnership of 8 CCGs, 12 Trusts and 3 Universities. Before I joined them as Innovation Delivery Lead, ICHP had undertaken a detailed audit of COPD in NW London and found consistent levels of under-performance across most key metrics. As a result they put out an offer to the CCGs to form a collaborative that could address the underlying issues.

The first four CCGs who joined were all recommissioning or about to recommission their services. They were asked to assess current and future pathway performance subjectively against the 13 elements of NICE guidance.

All 4 CCGs ranked current pathways as performing at 7 or less out of 10 and their proposed new pathways at 8 or more on all elements of the guidance. Download the Current service vs best practice PDF here.

In the end our scope was refined to focus on 1) developing common approaches to KPIs, 2) education and 3) contracting. We also committed to work to the wider principles of moving services into the community and consideration of uptake of “NHS Ready” innovations.

This process was, of itself, incredibly revealing. It showed how widespread the use of NICE guidance was in service design, but how it has been used as a tick-box exercise to ensure that new services delivered on all components, rather than to understand value and performance, an approach common across long-term conditions.

The fact that services could not be co-designed with those who would be delivering them highlights the dichotomy under the current set-up of a commissioner-provider split in our health economy.
Guy Gross

After some basic analysis we concluded that investing in just 3 or 4 components (e.g. structured self-management, smoking cessation, drugs optimisation, and pulmonary rehabilitation) could result in around 90+% of realisable savings and improved patient experience and outcomes.

It came time to engage with providers leading to the difficult question of whom to engage. I had built good relationships with the North-west London members of the London Respiratory Network (LRN) who strongly supported our purpose and helped refine the scope.

The choice was between working with in-area incumbents, which could be considered anti-competitive, or with out-of-area providers less familiar with local challenges and politics. The AHSN stepped in and instructed the use of out-of-area providers.

I engaged the LRN to help source the right people to bring around the table which proved very helpful in expanding and informing our working knowledge of successful services and teams in London and the South East. By now we had managed to involve representatives from 7 of the 8 CCGs, were working with the Healthy London Partnership and the Strategy Planning Group for NW London. We had also brought in key experts from north-west London in the emerging field of integrated respiratory care. It was important for all participants to understand the value, impact, make-up and costs of these services.

The fact that services could not be co-designed with those who would be delivering them highlights the dichotomy under the current set-up of a commissioner-provider split in our health economy.

On one hand we are all out to do the right thing by patients and yet there are significant vested interests that differ between providers and commissioners. It is a problem which is politically, financially and clinically sensitive and probably the most common cause of derailment of innovations that make it into a CCG’s business case.

As a further demonstration of this, we considered the rollout of a proven innovation which is a patient platform that supports self-management and costs around £30,000 per CCG. It targets a variety of patient cohorts including some not targeted by current services and has been shown to significantly reduce admissions.

The funding of such innovations most commonly comes from diversion of funds from the budget of the existing provider of the service. Putting this in context, we would have threatened to take that £30,000 from each of the £200-500,000 services inevitably limiting already stretched resources within the incumbent provider.

Through sensitive handling, a couple of local providers agreed to trial the tool to assess how best to work with them. It was important to coach the innovator in how to sell in to providers rather than CCGs, ensuring a message of collaboration and blending rather than displacement of services.

The ICHP work really focused on setting a common vision of what ‘good’ service design looks like. These services will be commissioned over the coming 3 years and should begin to look more homogenous. Providers will be asked to deliver integrated care with Trusts having more of a community focus, better engagement with Primary Care and meaningful education to enhance practice in respiratory management across the system.

As a result of these collaborations, do you feel there has been a reduction in unplanned hospital admissions in patients with moderate to severe COPD?

This work will of course impact on admissions; we have seen four services set up to deliver integrated care in London, and these areas have seen impact, not only on use of resources, but in significant reduction of admissions and readmissions, particularly Hammersmith & Fulham CCG.

More widely, what would you say is the principal benefit of NHS England’s focus on developing new care models?

New Care Models being developed are about enablement and empowerment. They enable and empower patients to take ownership of their disease and help clinicians move away from being all-seeing, all-knowing institutional paternalists to partners in care. The current paradigm conventional drivers with short-term, activity-based incentives driven by an in-year savings philosophy which is broken and unsustainable. With new ways of working we can finally begin to address the prevention and wellbeing agenda meaningfully.

If you can understand how someone lives and what matters to them in their daily lives, you are able to modify therapy accordingly

These models break the rules and allow for unconventional approaches with unconventional metrics. Their approach also encourages partnerships with early-stage businesses that would never have broken through the hefty barriers of NHS procurement otherwise.

Why is this important and what will ‘success’ through more integrated care look like for patients and practitioners?

Integrated care is fundamental to developing sustainable long-term disease management in the community. Bringing care closer to peoples’ homes is central to personalisation. If you can understand how someone lives and what matters to them in their daily lives, you are able to modify therapy accordingly to improve uptake and adherence. Inevitably this leads to improved outcomes and better quality of life.  

It is also key to reducing variation of practice in primary care. Commissioned specialist providers in the community can work with their GPs to educate and mentor them on best practice; these interventions are highly cost-effective and can be run virtually. The estimated savings in CCGs currently taking part in virtual respiratory clinics are upwards of £150,000 per year and, together with the integrated services, have been responsible for significantly reduced COPD admissions.

As the Accountable Care Organisation/Partnership models emerge (ACOs and ACPs), we will begin to see a more collaborative and joined up care system. Everyone across the system will share outcome-based KPIs, will prioritise prevention (10,20 and 30) over cure and will meet the challenges of digital enablement collaboratively to embed meaningful and life-changing enhanced services that empower patients.

In a place and at a time where it is easy to feel down about the future of healthcare, these new models offer opportunity to be excited and passionate. They open the door to innovation, they break down the barriers that exist between commissioners and providers, they allow us to support patients in health over illness and to take on a more supportive role in patient care.

This change in culture will be pervasive and change the very nature of our roles as clinicians. Over the coming years, digital enablement will mean spending more time monitoring our patients’ health and less time treating their illnesses.

Thanks for speaking with us today, Guy. 

If you have any comments or questions following this feature, please post them in the discussion area below.

 

Guy has an MBBS from Nottingham and an MBA from LBS. As Innovation Delivery Lead at the AHSN for NW London he has led several pieces of work across long-term conditions, taken several companies successfully into the NHS in London, and remains an evangelist of digital enablement and support of wellbeing both as a speaker and through contributions to DigitalHealth.London. 

Post medicine Guy honed his skills as a corporate innovator, consultant, institutional investor and entrepreneur across a number of industries . Winning the contract for the lion's share of the £3.5m National Shared-Decision Making Programme (under Right Care) helped inform his understanding of how to navigate the complex politics of the NHS and meaningfully engage top level senior stakeholders; these are lessons he took into his role with the AHSN.

He now helps businesses understand the "unknown unknowns" in the NHS and supports them to overcome these hurdles. For further information contact Guy at Guy@JPmed.co.uk