© Nuffield TrustCommissioning for long-term conditions:what do commissioners actually do?Dr Judith SmithDirector of Policy...
© Nuffield TrustAgenda• Our study• What we found about the practice of commissioning• Implications• Questions raised
© Nuffield Trust12 June 2013 © Nuffield TrustOur study
© Nuffield TrustOverviewAim:To explore the ways in which NHS commissioning can beenacted to assure high quality care for p...
© Nuffield TrustOverview (2)ApproachBroadly ethnographic, using mixed methods, and with regularfeedback to sitesSelection ...
© Nuffield TrustThree commissioning communitiesSomerset CalderdaleDiabetesStroke DementiaWirral
© Nuffield TrustCommissioning activity being tracked3 new services which beganoperating3 developments being discussedand p...
© Nuffield Trust12 June 2013 © Nuffield TrustWhat we found out about thepractice of commissioning
© Nuffield Trust1 The practice of commissioningWhat we found• Something much messier, withmuch more going on;• Process not...
© Nuffield Trust2 The labour of commissioningWhat we found• A huge amount of time and effortgoes into commissioning;• The ...
© Nuffield Trust3 Identifying the commissionersWhat we found• Multiple and ambiguous roles;• Providers often involved inco...
© Nuffield Trust4 The role of moneyWhat we found• Money did not seem to becentral to a lot of thediscussions we observed;•...
© Nuffield Trust5 The nature of changeWhat we found• Change can be very slow to bringabout;• Commissioners are sensitiveab...
© Nuffield Trust6 National ‘guidance’ in a local contextWhat we found• Top-down impetus to get thingsdone – this makes a s...
© Nuffield Trust12 June 2013 © Nuffield TrustImplications
© Nuffield TrustImplicationsCommissioning for long-term conditions is made up ofmultiple and labour-intensive processes• S...
© Nuffield TrustImplications (2)In commissioning care for people with long-termconditions, the relational aspects tend to ...
© Nuffield TrustImplications (3)The cycle of commissioning lends some order and routineto commissioning• It helps commissi...
© Nuffield TrustImplications (4)There are some critical enablers of commissioningpractice• Skilled managers, especially at...
© Nuffield TrustQuestions raised1. When it comes to the labour of commissioning, how muchis too much?2. To what extent doe...
© Nuffield TrustAcknowledgement and disclaimerThis project was funded by the National Institute for Health ResearchHealth ...
© Nuffield Trustwww.nuffieldtrust.org.ukSign-up for our newsletterwww.nuffieldtrust.org.uk/newsletterFollow us on Twitter(...
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Judith Smith: Commissioning for long-term conditions

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Judith Smith: Commissioning for long-term conditions

  1. 1. © Nuffield TrustCommissioning for long-term conditions:what do commissioners actually do?Dr Judith SmithDirector of Policy, Nuffield TrustThe Commissioning Show, Excel, London12 June 2013
  2. 2. © Nuffield TrustAgenda• Our study• What we found about the practice of commissioning• Implications• Questions raised
  3. 3. © Nuffield Trust12 June 2013 © Nuffield TrustOur study
  4. 4. © Nuffield TrustOverviewAim:To explore the ways in which NHS commissioning can beenacted to assure high quality care for people living with long-term conditionsTimescale:Two years (Mar 2010 – Feb 2012)Funding:National Institute for Health Research (NIHR) Health Servicesand Delivery Research programme
  5. 5. © Nuffield TrustOverview (2)ApproachBroadly ethnographic, using mixed methods, and with regularfeedback to sitesSelection of study sitesQuantitative metrics summarising 200 indicators used toidentify a cohort ‘high performing’ primary care trusts (PCTs)who were invited to take partData collectionObservation of meetings (n=27)Semi-structured interviews (n=124)Informal update interviews (n=20)Analysis of documents (n=345).
  6. 6. © Nuffield TrustThree commissioning communitiesSomerset CalderdaleDiabetesStroke DementiaWirral
  7. 7. © Nuffield TrustCommissioning activity being tracked3 new services which beganoperating3 developments being discussedand plannedSomerset - Remodelling of diabetescare into a three tier serviceWirral – Review of diabetic podiatry toresolve operational problemsSomerset – An early supporteddischarge (ESD) service for patientsrecovering from a strokeCalderdale – Review of existingprovision of diabetes care anddiscussion of plans for strategicremodellingWirral - Establishment of a newcommunity-based service for diagnosisand treatment of dementiaCalderdale – A strategic review of alldementia care
  8. 8. © Nuffield Trust12 June 2013 © Nuffield TrustWhat we found out about thepractice of commissioning
  9. 9. © Nuffield Trust1 The practice of commissioningWhat we found• Something much messier, withmuch more going on;• Process not happeningsequentially;• Not fitting an annual cycle;• Co-ordination and facilitation arebig parts of commissioningpractice;• Support for implementation also arole for commissioners.AssumptionA neat cycle of:• needs assessment• service specification• contracting• monitoring• review
  10. 10. © Nuffield Trust2 The labour of commissioningWhat we found• A huge amount of time and effortgoes into commissioning;• The scale of effort that goes intocommissioning may not relatedirectly to that of the service;• Lots of labour is associated withcollecting and handling data;• Decisions about whether to givepriority to a commissioning taskmay be based partly on theresources available to do the work.AssumptionCommissioning isconcerned withincentivising otherpeople to do some work
  11. 11. © Nuffield Trust3 Identifying the commissionersWhat we found• Multiple and ambiguous roles;• Providers often involved incommissioning tasks and events;• Commissioners helping toshape, track and undertakeimplementation;• Shared responsibilities acrosscouncils and PCTs;• Clinicians in many different roles.AssumptionCommissioners arepeople with money todistribute to meetidentified needs
  12. 12. © Nuffield Trust4 The role of moneyWhat we found• Money did not seem to becentral to a lot of thediscussions we observed;• Money often appearedlate on in the story;• The major decisionsappeared often to happenin parallel to the ‘nitty-gritty’ of commissioning.AssumptionCommissioningdecisions will be guidedlargely by concernsabout money
  13. 13. © Nuffield Trust5 The nature of changeWhat we found• Change can be very slow to bringabout;• Commissioners are sensitiveabout disrupting the local healtheconomy;• Change often entails moving staffbetween organisations;• Easier to bring in something newthan to decommission;• Senior and sustained projectmanagement is critical.AssumptionCommissioning is amechanism whichallows you to makeabrupt and radicalchanges to serviceprovision (de-commissioning and re-commissioning)
  14. 14. © Nuffield Trust6 National ‘guidance’ in a local contextWhat we found• Top-down impetus to get thingsdone – this makes a significantdifference;• A wide range of national strategiesand models of what to do;• Locally set priorities tend to bewithin this national context;• Savvy commissioners use thenational impetus to press aheadwith local work.AssumptionLocal decisions aremade bycommissioners inresponse to locallyidentified needs.
  15. 15. © Nuffield Trust12 June 2013 © Nuffield TrustImplications
  16. 16. © Nuffield TrustImplicationsCommissioning for long-term conditions is made up ofmultiple and labour-intensive processes• Some of these align with the commissioning cycle, othersdo not – some are conspicuous by their absence;• Commissioning practice is less often focused on wholeprogrammes of funding and service provision;• It tends to be about more marginal elements of services;• Decommissioning rarely features.
  17. 17. © Nuffield TrustImplications (2)In commissioning care for people with long-termconditions, the relational aspects tend to dominate• Lots of time and effort goes into service design andspecification, stakeholder engagement, planning andconvening;• This work is often critical to bringing about change, but inexamples of effective commissioning, there was arecognition of when it was time to ‘get transactional’;• Questions for the reformed NHS include whether it canafford so much relational commissioning.
  18. 18. © Nuffield TrustImplications (3)The cycle of commissioning lends some order and routineto commissioning• It helps commissioners to tie in with the financial planningcycle, contracting, etc.;• Long-term conditions are less easily ‘commodified’ thanelective services;• They may require a different approach to risk-sharing andcontracting, with providers incentivised acrossorganisations.
  19. 19. © Nuffield TrustImplications (4)There are some critical enablers of commissioningpractice• Skilled managers, especially at middle-management level– boundary-spanners;• Accurate and timely data;• A judicious amount of meetings and workshops;• Sustained involvement of clinicians;• Careful use of national guidance at local level;• Clarity about the outcomes expected of commissioning;
  20. 20. © Nuffield TrustQuestions raised1. When it comes to the labour of commissioning, how muchis too much?2. To what extent does the blurring of roles challenge thecommissioner/provider split? Does this matter?3. Should money have a more central and specific role incommissioning conversations?4. Are commissioners held back by caution, or byconstraints? Will GP commissioners be more radical?
  21. 21. © Nuffield TrustAcknowledgement and disclaimerThis project was funded by the National Institute for Health ResearchHealth Services and Delivery Research programme (project number08/1806/264).The views and opinions expressed therein are those of the authors anddo not necessarily reflect those of the NIHR HSDR programme or theDepartment of Health.
  22. 22. © Nuffield Trustwww.nuffieldtrust.org.ukSign-up for our newsletterwww.nuffieldtrust.org.uk/newsletterFollow us on Twitter(http://twitter.com/NuffieldTrust)© Nuffield Trust

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