Commissioning, contracting and tendering in England: your specialty’s experiences

Background:

The RCP has been engaged in a range of work related to commissioning and service-planning, including related fields such as contracting, tendering and financial incentives. This work has grown in scale and breadth since the implementation of the Health and Social Care Act in April 2013, with projects ranging from the launch of the Clinical Commissioning Hub on the RCP website, to ongoing Clinical Standards activity to engage with Clinical Commissioning Groups (CCGs).

As part of the next phase of this work, we will be publishing a short report on commissioning and service-planning in England later this year. Compiled on the basis of input and intelligence gathered from specialty societies, members, fellows and patients, this report will highlight some of the key challenges in the English commissioning system, present case studies of good practice, and propose some specific recommendations for improvement. 

To gather further input into the report, specialties are invited to respond to the questions listed below. 

Please note:

• The questions below apply to England only.
• Please consider all relevant commissioning organisations in your answers. This could include CCGs, NHS England, Public Health England and local authorities (councils).
• We welcome any real-life examples you’d like to use to illustrate your answers.
• We would like to identify some examples of good practice that we could use as case studies that others can learn from. Please tell us about any good-quality commissioning practices you’ve come across.
• Where possible, please try to explain whether your examples relate to commissioning as a whole, or to a specific issue which is related to commissioning (eg tendering or contracting).
• Our report will be short (about eight pages). This means it will take an overarching approach that focuses on the main, broad issues affecting the commissioning system as a whole in England. Your specialty’s feedback will help us to identify what these main issues are, and what recommendations we should make to address those issues. The report won’t go into specific details about individual commissioning exercises, specialties or CCGs.

Your name and position:  Professor David Oliver, President, British Geriatrics Society

Your specialty: Consultant Physician in Geriatric and General Medicine, Royal Berkshire NHS Foundation Trust, Reading

Section A: Joined-up patient care

In your specialty’s experience, how far do existing commissioning arrangements help to ensure a joined-up experience of patient care across the care pathway?

In the speciality of Geriatric Medicine (with many of our members doing lots of General Internal Medicine, Acute Medicine, and others doing Stroke or Community/Interface Geriatrics and others still offering speciality services, for instance in Orthogeriatrics, movement disorders, memory disorders, falls), whole pathways of care are critical. We deliver a big percentage of the acute medical take for adults and tend to look after a high percentage of inpatient beds. We tend to look after patients who require post acute rehabilitation, often social care and support from carers, intermediate care, end of life care etc and often patients coming into hospital from care homes. Our community and interface geriatrician members also deliver services in care homes, community hospitals and in support of discharge teams, virtual wards, admission prevention etc. 

For frail older people with complex needs using multiple services, commissioners need ideally to commission for whole “end to end” pathways of care, starting with proactive case management, community teams, rapid response teams, acute care pathways which reduce bed occupancy and get people back home quickly, adequate intermediate care capacity (both step up and step down) and good cross-working between health and social care (e.g. medical input into care homes). 

There are some good examples of commissioners driving these types of pathways in conjunction with colleagues from secondary care, community services, mental health, social care etc. But it is very patchy and variable because the CCG role is in its infancy and many developments have been driven by providers (especially integrated providers). Also primary care delivered but not commissioned by GPs is crucial and this has been outside commissioning. If we look at three examples – capacity and responsiveness in intermediate care services (See NHS Benchmarking Intermediate Care Audit), and healthcare inputs into care homes  (see “Failing the Frail”), or end of life care for older people - capacity, responsiveness  and access are very variable 

So it is in its infancy for general, whole systems work. There may have been more success for Stroke (long established strategies and pathways and easier to commission for a single definable condition) and in some localities for falls, fractures, osteoporosis, but again it is very variable and patchy at this stage.

Why is this the case? What could commissioners do to improve this aspect of commissioning?  

The NHS was preoccupied with structural reorganisation from 2010 to 2013 as the recent Kings Fund Report on Health Policy under the coalition government showed. CCGs are only just finding their feet. Social care funding has been drastically cut. There is a workforce crisis in primary and community care. Many contracts with community providers have no response standards, performance specifications etc. Properly integrated working relies on a good inter-agency implementation group with shared goals and vision and each organisation prepared to collaborate. But pressures from NHSE/DH/Monitor/CQC tend to focus on individual organisations. Incentives/financial instruments/outcome measures favouring individual organisations don’t help. Also with so many pathways to commission, CCGs cannot possibly have expertise in everything. Though with most of the money across all sectors going on older people with complex needs, the pathway for them cannot and should not be ignored. But fellow geriatricians are not always engaged within their own health economies.  We also need high quality commissioning instruments which can be populated with numbers, business cases, outcome measures, evidence and readily downloaded. These exist (For instance, the DH Falls and Bone Health Commissioning toolkit,  BGS “Fit for Frailty” resources, NHS England “Safe Compassionate Care” BGS “Care Home Commissioning Guidance” and to an extent the “Silver Book” on urgent care for older people. These are not always reliably disseminated and adopted. We are also bedevilled by “magical thinking” and overpromising about reductions in urgent activity or shifting care outside hospital at a scale and pace hard to achieve, and distracted by repeated one-off allocations of “pilot money” which stop sustained focus on implementation and stability.

What could other organisations do to support commissioners in this respect? (e.g. Trusts, Monitor, CQC, NHS England, professional bodies). 

Financial instruments, payment mechanisms and the unintended consequences of targets need to be looked at e.g. 4 hours target driving people into hospital, marginal tariff for urgent activity, partial payment for readmission, all drive the wrong behaviours and penalise providers for elements of the care pathway beyond their control. Having social care means-tested and rationed, community health services on block contract and acute trusts on payment by activity all lead to fragmentation. Primary and community care, and especially social care, are underfunded and understaffed and we have the fewest acute beds per 1000 population of all but one OECD country. So funding (as set out in Kings Fund and Barker Commission reports, for instance) and financial instruments need to foster more collaborative working. Health and care economies need more freedom to innovate with budgets. We also need a functioning single transportable patient record to be shared across all agencies and accessed by all staff and a set of whole system (rather than single organisation) outcome indicators.

Trusts should engage fully with commissioners and other local providers and the public in whole pathway redesign and the relevant specialists being fully on board. There is some evidence that vertically integrated organisations (which run their own community services) have a better chance of whole systems working. Trusts also need to do all they can to improve care within the acute care pathway, minimise delays and reduce harms before resorting to blaming community partners. And they should be prepared to cede some control and activity (e.g. moving some outpatient work out of hospital). 

Monitor should stop putting unhelpful short- term pressure on organisational leaders which prevent them planning joined-up services for the medium term and should incentivise and measure whole systems working rather than focussing on individual organisations. They also have the balance of competition versus collaboration wrong with several examples of organisations wishing to collaborate and being prevented from doing so. It should also create tariffs/financial instruments which incentivise whole systems working and which do not penalise providers with marginal rates thus putting them at risk financially – especially for things outside their gift – such as urgent demand or readmission rates. Monitor also pushes management consultancy onto providers and health economies – often offering undeliverable promises on savings, efficiencies and activity and therefore distracting local leaders.

CQC has created a recipe for dis-integrated commissioning by setting up separate inspectorates for hospital, primary and social care. No-one inspects the quality of commissioning (for instance capacity) in intermediate care or support for care homes). They also focus on what is easily measureable and not the delivery of person centred, co-ordinated outcomes or whole systems working.

NHS England is in its “post Stevens” infancy and has been pre-occupied with its own start up. Recent debates on the tariff, the role of specialised commissioning, commissioning of GMS services, the role of CSUs illustrate this. There is promise in the stability, the long- term vision and new models set out in the Five Year Forward View but we will have to see what happens following the general election. There are still too many pilots, short term projects etc which don’t foster long term vision.

Professional bodies such as RCP and specialist medical societies (in our case BGS and also British Association of Stroke Physicians, Faculty of Old Age Psychiatry, Nursing and Therapies colleges/societies, Association of Palliative Care Physicians) could do more to set out clear visions for “what good looks like” backed by key evidence (and in this climate this evidence should include anything on cost or activity reduction as well as improving patient outcomes and safety). Tools to estimate local population need and costs of service, key outcome measures and links to examples of what  has worked well in other parts of the NHS are all part of the evidence base. There are examples such as those quoted above  - also the Kings Fund Paper “Making Health and Care Systems fit for an Ageing Population” - and others which can be useful self-assessment tools and tools for commissioners/providers (e.g. major national clinical audits). However, whilst colleges and societies should of course advocate for high quality, evidence-based patient care delivered by people with appropriate training, the tone is important. This tone should be “How can we as specialists help you to deliver gains across systems that address your issues”? This is different from “We are the expert authority and here is what you should commission” (an approach I have seen and which alienates commissioners and primary care colleagues).

Section B: Sustainable services

In your specialty’s experience, how far do existing commissioning arrangements help to ensure services are stable, sustainable and can plan for the population’s longer-term care needs?

So far CCGs have been preoccupied with authorisation, have been developing new competencies, have lost many experienced managers and, by and large, much of the innovation has been driven by providers with commissioners late to catch on. There are notable exceptions and examples of genuine cross-agency working – for instance in County Durham CCG, commissioning good health care for care homes but commissioning services for frail older people with complex needs is in its infancy. Virtually every CCG has a focus on frail older people, people with dementia, people with one or more long term conditions, care planning for patients at the top of the risk pyramid but it is too early to see these plans translating into concrete deliverables and in some cases (e.g. the expectations of big reductions In urgent activity as part of Better Care Fund plans), there is too much magical thinking and overpromising. Partly due to panic about the financial challenge and urgent care crisis, partly due to short term allocations of government money and concerns over winter pressures, we have fostered a culture of short term “panic buying” with numerous pilots and projects never allowed to mature, stopped before they have a chance to deliver and leaving more and more complex “debris”.

Why is this the case? What could commissioners do to improve this aspect of commissioning?  

As the Five Year Forward view alludes to, new service models need time to mature and will take 3-5 years to deliver. They should be based on evidence of what is realistically achievable (e.g. around urgent activity) and not magical thinking and overpromising based on how much money needs to be saved or poorly evidenced consultancy reports. They need to collaborate far more closely with secondary care colleagues (especially in high volume, bed holding specialities like geriatric medicine) and with social care, need to consider the quality and variability and access in primary (GMS) services – not currently commissioned by CCGs - and also to put some meaningful performance specification in contracts with community health providers . Currently as the National Intermediate Care audit shows, there is very patchy access to these alternative services outside hospital. They also need to plan adequately for end- of- life care and for support for care home residents and for low level preventative interventions that can keep people well and independent. All of this needs to be part of an overarching vision with all agencies signed up to an end to end care pathway based around older people and their carers, and not around short term performance and financial pressures and narrow organisational interests. They also need to look at poor or variable practice e.g. around discharge from hospital, care home placement, post discharge support, care co-ordination and be prepared to learn from, and import recognised good practice models, from elsewhere rather than re-invent wheels locally.

What could other organisations do to support commissioners in this respect? (eg Trusts, Monitor, CQC, professional bodies) 

Professional bodies can have a key role in issuing high quality evidence-based commissioning guidance. The BGS has real expertise and a track record in this area. For instance the Care Home Commissioning Guidance on healthcare for care home residents.  or the “Fit for Frailty” resource aimed at commissioning and providing high quality services for people living with frailty 

Geriatricians including the NCD were heavily involved in the National Falls and Bone Health Commissioning Toolkit for Falls and Fractures which has had real traction and profile.  See here. 

The BGS President Professor David Oliver is the lead author of the 2014 Kings Fund Paper “Making Health and Care Systems fit for an Ageing Population” setting out good practice models aimed at commissioners and providers and which has been widely downloaded and used in commissioning plans 

NHS England (led by Geriatrician and current NCD John Young) has also produced commissioning guidance on the care of older people with frailty “Safe Compassionate care for frail older people using integrated commissioning”  

NHS Benchmarking in its National Audit of Intermediate Care provides a detailed resource for looking at the whole range of out of hospital services for older people including patient- reported outcome measures, cost, and cost effectiveness 

The Silver Book on ‘what good looks like’ in urgent and emergency care for older people and the National Hip Fracture database and audit are other examples of setting out clearly ‘what good looks like’ in services. Both give commissioners standards to commission against, tools to aid commissioning, and outcomes they can compare transparently with outcomes in other health economies

There are other examples such as the RCGP guidance on commissioning end of life care and the Gold Standards Framework.

NHS England is not attempting to support the 5 Year Forward View and proposed new models of care with commissioning instruments and toolkits

In our experience, commissioners and local partners welcome such off-the-shelf resources populated by key evidence, key facts and figures, population modelling, key outcome etc but they are most useful as part of a genuine cross-agency collaboration based around the whole end-to-end care pathway.

With regard to Monitor and the CQC, their current behaviour is extremely unhelpful as they continue to regulate and pressurise individual organisations when they need to look at whole health economies. For instance, punishing Acute Trust Chief Executives for over-crowding, delayed transfers or re-admissions when the problems lie in the wider health economy is the definition of unhelpful.  The CQC has created disintegration by having separate inspectors for health, social and primary care and no inspector for commissioning or whole systems working

Never forget in all of this, the key role of workforce planning including the crucial allied health professional workforce.

Section C: Education and training

In your specialty’s experience, how far do existing commissioning arrangements take appropriate steps to ensure the education and training needs of the workforce are provided for?

We can see very little evidence at the moment - beyond specific areas such as embedding end-of-life care planning and support through the Gold Standards Framework, or ensuring that staff  are dementia-trained - of commissioning addressing these issues. If we are to have a radical shift towards prevention, care co-ordination, care closer to home, care for people with complex comorbidities and frailty, support for carers - and not just addressing single disease entities, we need the whole workforce equipped with these competencies (as set out in “Fit for Frailty”).  We are a million miles from this currently.

Why is this the case? What could commissioners do to improve this aspect of commissioning?  

We could ensure that education, skills and training are integral to all plans – not an afterthought.

What could other organisations do to support commissioners in this respect? (eg Health Education England, Trusts, CQC, professional bodies)

They could ensure that the workforce has the right skills and capabilities to do the job most of them will be doing – supporting older people, often with frailty, often with dementia, often with several long term conditions and polypharmacy, often using multiple services. Therefore the focus is on care planning, care co-ordination, post acute rehabilitation, prevention, acute general internal medicine/geriatric medicine, intermediate care services to ensure the right workforce with the right skills in the right place to deliver the vision. This includes people who are not per se specialists in the care of older people but who will have to do a lot of that work day to day.

Section D: Allocating resources

Commissioners rely on data (such as clinical coding data) to identify what activity happens in the NHS and how much money should be allocated to different types of activity. How effectively do commissioners use this data?

Coding of patients with multiple co-morbidities, with frailty, with Dementia, with co-morbid disability is currently very poor and patchy both in GP Read codes, hospital episodes and in intermediate care services on block contract. Social care data are poorer still and the systems don’t cross link with one another, via unique identifiers, nor are there shared records. In addition, a fixation over data governance hampers progress. THE RCGP Coalition for Collaborative Care Handbook on risk stratification tools is good on overcoming some of the data governance issues. But even common events like falls, delirium, sudden immobility are currently poorly coded and we are only just starting to identify people with frailty through use of the new Electronic Frailty Index (NHS England) for Primary Care System 1 database

Section E: Clinical involvement

In your specialty’s experience, how far do existing commissioning arrangements engage and involve clinicians effectively? Why do you think clinical involvement in commissioning matters? 

It is very variable. In the best places, there is a good cross agency group looking at whole pathways, and with secondary care geriatricians or community/interface geriatricians and relevant nursing and AHPs at the table to give expertise and input across whole care pathway. Leeds is a good example and has been written up as a Kings Fund paper on specialists working across into community. Sheffield and South Warwickshire are also examples written up as Health Foundation studies. And there are other example of cross agency working with speciality input for certain parts of the pathway e.g. care home commissioning at Ashford and St Peters, or in County Durham. However, the picture is patchy. Many secondary care based geriatricians feel excluded from/not involved (though, as with all hospital specialities, this is sometimes as much their fault as that of local commissioners). In other places (cock-up rather than conspiracy), the commissioners haven’t got their act together or haven’t thought to engage secondary care specialists. In other places service developments have been driven from providers (especially where vertically integrated). In some places, there is actually hostility to secondary care experts with the focus on unrealistic expectations for admission prevention, care closer to home and illusory savings

Why is this the case? What could commissioners do to improve this aspect of commissioning?  

Regard specialist doctors as partners in commissioning and co-opt their expertise. Specialist doctors don’t want lots of people defaulting into acute beds, staying too long and then being re-admitted when they go home. They want to help pathway redesign but need to be included. In turn those secondary care specialists need to be prepared to change the way they work to focus more on whole system priorities rather than personal interests, and sometimes to stop some clinical activities to focus more on partnership working. They also need to learn enough about the agenda pressures, financial and regulatory frameworks facing community colleagues/commissioners to engage effectively and constructively with them. It is also important for speciality services to improve whatever is in their gift as providers before reflexively blaming poor commissioning/inadequate community provision

What could other organisations do to support commissioners in this respect? (eg Trusts, professional bodies)

See my answers above on key facts and figures, commissioning toolkits, key resources, showcasing and sharing good practice examples. Given the huge consultancy spend in the NHS (Oliver D BMJ 2014), we also need to get much better at the NHS helping the NHS, with people able to learn from sites that have commissioned and delivered good services for older people already. Localism is important in terms of tailoring to local circumstances and historical provision. At the same time, there is no sense in “1000 flowers blooming” when certain service models/job descriptions/outcomes/pathways have been shown to deliver consistently. Peer support from fellow clinicians via speciality societies and colleges Is key and they in turn need to work more closely with NHS England/NHS IQ and others.

Section F: Research and academia

In your specialty’s experience, how far do existing commissioning arrangements support research effectively?

With the establishment of AHSNs, Public Health England, Health Education England, all in recent memory and with the service therefore in chaos – not to mention establishment and authorisation of CCGs and financial austerity - in our experience academic and research activities are something of an afterthought in commissioning.

Why is this the case? What could commissioners do to improve this aspect of commissioning?  

Given the real focus on quality improvement projects, cost effectiveness, service reconfiguration, interventions to attenuate the urgent care crisis and to shift more care closer to home, the need to reduce unwarranted variations etc., we need to build in more service evaluation research as part of commissioning new services.  We also need to move away from dependence on consultancy and on short term pilot projects stopped before they have time to mature

What could other organisations do to support commissioners in this respect? (eg Academic Health Science Networks, Academy of Medical Sciences, National Institute for Health Research)

As above

Section G: Other issues not covered above

Are there any additional examples of good practice you’d like to highlight which are not already covered in your answers above?  

The BGS, the Kings Fund, NHS Benchmarking, NHS England, and the HSJ Commission on Frail Older People, the RCN work on improving Dementia Care, good practice examples from the Hip Fracture Database (all alluded to above) and from the Acute Frailty Clinical Network and Health Foundation studies such as those from Sheffield and South Warwickshire on patient flow, all furnish us with numerous good practice examples and commissioning toolkits – we are just too slow to implement.

Is there anything else you’d like to tell us that could help inform our upcoming report on commissioning in England?

With other commentators, we highlight the necessity for much greater alignment between commissioning, funding and regulatory systems if health economies are to function optimally.