Outcomes-based commissioning

Source: National Health Executive Jan/Feb 2013

Dr Mary Keenan, medical director of Oxfordshire Clinical Commissioning Group (OCCG), discusses its new patient-centred approach.

Imagine a model that puts patients at the heart of commissioning – that plans and manages services in a way that takes their views and opinions into consideration, rather than focusing on the volume of work carried out.

It may sound unattainable, but the creation of new commissioning groups offers the unmissable opportunity to think about services in a different way. Oxfordshire CCG is launching such a model, aimed at bringing patients to the centre of commissioning for three key areas of care.

NHE spoke to OCCG medical director Dr Mary Keenan about the new approach, and how it could boost quality across Oxfordshire.

Out of the ‘too difficult’ box

Outcomes-based commissioning is still in its early stages, and the exact details of how OCCG will implement the changes are still being decided.

The approach has been piloted in small areas around the country, including in Milton Keynes under Dr Nicholas Hicks, who is director of public health for the town and also programme director for direct commissioning of public health for the NHS Commissioning Board.

These results have fed into the new approach, and Oxfordshire is the first CCG to begin planning mainstream services for patients in this way. Dr Keenan said the creation of OCCG as a new organisation offered a fresh chance to change a system which has been in place for many years.

She explained: “We realised that the current system of NHS contracting isn’t fit for purpose any longer. That’s not to say it’s dangerous – we think it’s giving perverse incentives and we really want to focus on what’s important to people who have to use our services.”

The group wants to make a difference, she added, particularly after inspiration from Hicks’ pilot.

“We decided that we really wanted to work with them and adopt this way of working, in three areas. It’s fortuitous, hearing about it and it fitting in with our vision, mission and values.”

Dr Keenan was quick to point out that this was about the quality of care, rather than remodelling services to generate efficiencies: “It’s not a cost-saving exercise; it’s really focusing on quality.

“We are hoping that because we’re focusing on quality, we’re reducing replication of effort and that the costs won’t increase. The primary focus is quality and user experience.”

Realigning incentives will be “a really difficult thing to try to change”, she acknowledged, and suggested that such innovation has been held back in the past because of a sheer lack of time and resources considering the urgency of other issues.

She added: “I don’t think it’s been set up deliberately to incentivise things wrongly; it’s just arrived at that state over a number of years. It’s been in the ‘too difficult’ box until now.”

Defining frailty

The areas selected for the new approach are frail and elderly patients; maternity services; and mental health.

Dr Keenan explained: “It’s no secret Oxfordshire’s got one of the biggest problems of delayed transfers of care in the country so we felt that it was a priority area for us.”

This means that the frail and elderly area could prove the most difficult, due to the integral complexity of conditions and care required. Even defining the category could be problematic, and may need the CCG to determine health more holistically, rather than simply by age.

“You can have a 65-year-old who is in incredibly good health, who could run marathons. Or you could have a 55-year-old who you could term as a frail older person – even that is proving as a little tricky.

“Maternity by definition is a time-limited thing with an obvious output and obviously frail and elderly isn’t.”

But she added: “Just because it’s difficult doesn’t mean we shouldn’t try.”

Learning curve

One major obstacle to change is the human resistance to reorganisation. Dr Keenan admitted that this could be challenging, particularly during such a time of upheaval. “I’d be foolish if I said there’d be no resistance," she said.

“A lot of our staff have been used to one way of working. A lot of them are very excited at considering working in slightly different way, which will be less hierarchical and more innovative. It will be a learning curve for all of us really.”

In terms of timescales, initial work has begun with representatives from the three major areas the commissioning will focus on, and will progress in terms of readiness. “Some are further ahead than others and some will be easier than others,” she said.

Incentives and innovation

The sort of incentives being considered for the strategy may include retaining independence, allowing people to stay in their own homes rather than hospital and “not focusing overly much on a medical model”.

Dr Keenan said: “That’s not to say that people don’t want to be healthy but probably the most important thing is to be enabled to be independent and have their own autonomy.”

Other features could involve the health and wellbeing of a mother and baby after birth and patients’ recovery and rehabilitation after injury.

The results of Oxfordshire’s approach will undoubtedly be of interest to CCGs around the country, and may be particularly useful when searching for new ways to provide care.

“I would imagine that they’ll be a whole host of services that will be wanting to look at in this way,” Dr Keenan commented. “I’m sure they’re watching what we’re doing. Although I think we’re amongst the first to look at these things, I would hope that we’re not the only ones who would think patient-centred care is important. I’m sure we’re not.

“We’re in a difficult position in Oxfordshire – we’re amongst the lowestfunded CCGs in the country. In very many ways it is difficult but out of necessity you get innovation.

“I suppose that means we’re a little bit more up for doing things differently – because we have to.”

The launch

More than 120 people were invited to OCCG’s launch event heralding the new outcomes-based commissioning model, allowing them to find out more.

Dr Keenan called it a successful event, with some “really useful contributions from our patients and user reps”.

The conference, on January 8, allowed commissioners, clinicians, patients and carers to give their views on how the model could work. Attendees included voluntary and patient organisations, local GPs and senior officials from health trusts, local government and the Department of Health.

Dr Stephen Richards, Chief Clinical Officer for OCCG, said: “The health reforms and our new role as clinical commissioners allow us to do things very differently. Our vision is to develop health services across Oxfordshire which are truly focused on patients and their carers. This means breaking down organisational barriers and challenging ‘silo thinking’.

“I was immensely encouraged by the number of senior people from health services who attended the conference, and their eagerness to explore this new approach and to discuss it openly with patients and their representatives. This is the start of a journey but I believe that there is a huge willingness for us all to work together to achieve something truly remarkable for our patients.”

iStock 000002286486Medium


Dr Bryan Spencer   13/03/2013 at 13:22

Mid Essex CCG are working on a new pathway for " Frailty " We are developing a Frailty Register in GP clinical systems and will create a database of activity and costs ( including social care ) for identified cohorts of these at risk individuals. The intention is to develop a "year of care " tariff and commission an " accountable Lead Provider " to provide the out of hospital care to support these people and reduce unplanned admissions ( will be integrated health and social care provision ) . We will be commissioning on an outcomes based model. Might be good to share learning on this. Dr Bryan Spencer Vice Chair Mid Essex CCG

Anonymous   13/03/2013 at 13:26

"Imagine a model that puts patients at the heart of commissioning". Nice soundbite, but: 1) Do the vast majority of patients know what commisioning is? 2) If they did, would they want to be 'at the heart of it', or prefer just to attend a hospital and receive appropriate treatment?

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