Health Service Focus

The clinical commissioners are coming – some case studies of impact

NHS Clinical Commissioners (NHSCC) – established through a partnership between the NHS Alliance, National Association of Primary Care and NHS Confederation as the new independent collective voice of CCGs – gives some examples of CCGs already making an impact on patient care.

It may still be some months until Clinical Commissioning Groups (CCGs) officially take up their responsibilities, but they are already demonstrating their potential to make a real difference to patients and communities.

These impact in very different ways, some directly obvious to patients while others improve services unseen. From providing better end-of-life care to reducing unwarranted variation in health service delivery, CCGs are working in multi-disciplinary teams to deliver great outcomes for their populations.

Despite the considerable demands on clinicians’ time involved in establishing the structure of CCGs, there has been real progress in improving services for patients. Before CCGs even formally exist as independent commissioning bodies, there are already demonstrable outcomes from some of these changes.

These two case studies demonstrate how clinically lead commissioning working with patients, carers and the wider practice team have the opportunity to transform care for patients.

Dr Charles Alessi, interim Chair of NHS Clinical Commissioners has commented: “These clinical commissioners have tackled issues head on, drawing on experience of front line staff, their knowledge of the local community and working with local managers. They put much time and effort into it. They worked through their own solutions and, undoubtedly, they have had to jump a few hurdles. They involved colleagues in primary and secondary care. They listened to patients’ concerns and responded to their needs.”

These case studies show the commitment of healthcare professionals to improving care for their patients. They demonstrate clearly how these CCGs (even before they are formally established) are looking different and feeling different and are putting patients at the heart of the health care system and are designing and re-designing services to meet their needs. But this is just a snapshot of what is happening across England.

Every planned CCG has a story to tell. And as they move towards taking on their full responsibilities, the number of those stories will increase as will the benefits for patients.

Reducing unwarranted variation

Member practices of Nottingham North and East Clinical Commissioning Group felt there was a need for rigorous scrutiny of the provision of clinical care – where the vast majority of resources are used.

With significant variation in many aspects of clinical work and frustration that good practice is not adopted everywhere; a more sophisticated approach to tackling unwarranted variation represented an important source of improving efficiency and quality.

Practices wanted to understand how they were performing so that areas for improvement could be supported and best practice promoted where there was excellence.

Building on previous internal benchmarking, work as Practice Based Commissioners along with external (other CCGs) data development of a Balanced Scorecard started in June 2011. The scorecard adopts a whole system approach including referral activity, electives, non-elective activity, A&E attendance, access, patient experience, health checks, vaccinations/immunisations, prescribing and enhanced services. A rolling schedule of practice visits for clinicians by clinicians also began in early 2012.

Clinical members of the Practice Forum determined the new approach to measuring practice activities and approved a multiprofessional group (GPs, allied health professionals, practice nurses, public health, practice managers, CCG staff and Local Medical Committee) to design the scorecard. A lead doctor was appointed as clinical champion with governing body clinicians maintaining oversight.

Areas of good practice and those for improvement were highlighted for each practice. A ‘buddying’ system of sharing was initiated using well-established Locality Fora. Practice Learning Time events sought to transfer learning from a neighbouring CCG following their cultural success through peer review of referrals before being made. Their lead clinician led the session to share their experience.

The scorecard approach helped contribute to early identification of diabetes care for an innovative clinical change management programme. The CCG Diabetes Lead is working with colleagues in secondary care to facilitate the discharge of approximately 170 patients with Type 2 diabetes.

The programme is supporting practices to improve skills and confidence in effectively managing these patients (within NICE guidelines) as well as improving the care of patients already looked after in primary care.

The work is already demonstrating impacts that are of benefit to patients including improved delivery of childhood immunisations/ vaccinations and greater awareness among practices of the range of enhanced services available. Furthermore it has delivered a 10% reduction in elective referrals to secondary care resulting in savings of £560k in 2011/12 (compared with a national reduction of 1%).

It has also had the effect of improving clinical ownership and accountability between member practices and the CCG via the challenge to reduce unwarranted clinical variation.

This has led to increased local clinical leadership with solutions being owned by the practices rather than being seen as topdown imposed solutions.

Bringing end of life care closer to home

Research shows that around 70% of people would prefer to die in their own home, but the reality is that around 60% still die in hospital. In response to a consultation by NHS Nene Clinical Commissioning Group with patients and their families, the public, GPs and staff, a common desire was expressed to develop more support on choice for patients at the end of their life.

Following this, public focus groups were carried out to obtain views on the types of services that may be required and additional research carried out to evaluate current service offerings and understand logistical elements.

The insights that were captured were then used to develop the Nene CCG end of life service, which aims to reduce the proportion of people dying in hospital by 9.7% by 2013. It also seeks to provide timely and high quality care to patients when they need it at the end of their life. Work with local GPs, acute and community based clinicians and professionals from carer and voluntary agencies, has led to the redesign of the Northamptonshire End of Life service that offers:

• A 24/7 central point of contact where care is coordinated
• A nurse-led rapid response service providing domiciliary based care within an hour of referral
• End of Life link nurses in both acute hospitals to support end of life discussions with patients and their family, and facilitate timely safe discharge home where this is the patient’s expressed wish.

But ultimately this is about the patient and their family and as James, husband of a patient who used the End of Life service said: “I think more people should die at home really. I had all the support I needed – there wasn’t anyone else I needed really because they were all here.”

In their case this involved coordinated support from a range of services including Hospice at Home, District Nursing, Age UK, Cynthia Spencer Hospice and Macmillan.

Janet died at home from terminal cancer in October 2011. She went into Cynthia Spencer Hospice in July 2011 but James was keen to have her back home. He underwent training to use hoists and Janet came out of the hospice.

When Janet came out she started off with two carers visiting twice a day and a twice weekly visit from the district nurse. As the tumour spread and the cancer worsened, Janet received visits from two carers three times a day, as well as regular visits from the Hospice at Home service, GP and district nurse.

On the day Janet died, James called the Northamptonshire Out of Hours service at 7.30am. They were visited by Age UK and then the district nurse who had to change Janet’s prescription in the syringe driver. Janet died peacefully at home at 10.30am.

James said: “I had support from all the services, there were so many people that got in touch, I lost count. I think more people should die at home really. I had all the support I needed – there wasn’t anyone else I needed really because they were all here.”

The service is already well on its way to achieving the aim of reducing the proportion of deaths occurring in hospital. There has also been a 26% reduction in excess hospital bed days experienced by those at the end of their life, compared to the previous year.

Dr Matthew Davies, End of Life GP lead for Nene Clinical Commissioning Group, explains: “In addition to choice of place of death, it is also vitally important that adults at the end of their life should receive appropriate, high quality care from services and support that focuses on their individual needs and that of their carers.”

(The names of the patient and her husband have been changed to protect their privacy.)