Health Service Focus

Commissioning Show 2015

More than 8,000 people attended the combined Health+Care and Commissioning Show 2015, engaging with the sector’s biggest organisations and companies and hearing from virtually everyone who matters in healthcare. Sam McCaffrey and David Stevenson report.

NHE was the official media partner for the Commissioning Show, and our team were at London’s ExCeL Centre for the duration.

Timed to coincide with the launch of the show was a survey on NHS priorities, suggesting the areas of most concern were elderly care and GP access.

Dr Michael Dixon, chair of NHS Alliance, senior adviser to NHS Clinical Commissioners and a member of the NHE editorial board, said: “Commissioners now need to explore exactly what sort of access patients actually want, and whether this is just for unscheduled conditions – and can be with any local GP thus preventing unnecessary hospital use – or whether patients and public are asking more than this at a time of limited manpower and resources.”

Health secretary Jeremy Hunt compared CCGs to “spiders in the centre of a web”, with GPs given yet more control over services delivered across local health economies.

He told the audience he believed in “intelligent transparency” and added: “We want to replace targets and top-down management with clinical accountability.”

He praised the fundamental tax-funded basis of the NHS, saying it eliminated some of the perverse incentives found in insurance-based systems, and said there is no ‘choice’ between safe care and financial discipline – safer care is cheaper in the long run as well as better for patients, he said.

Pioneers

At a session on using integration to support the independence of vulnerable people in Cornwall and the Isles of Scilly, the audience heard more about the Living Well pioneer programme.

Tracey Roose, chief executive of Age UK in the region and Living Well programme director for NHS Kernow, and two members of the CCG – Dr Tamsyn Anderson and Dr Colin Philip – spoke about progress.

The programme is based on a proof-of-concept pilot in Newquay that demonstrated significant improvements to wellbeing, fewer emergency hospital admissions with previously dependent people now offering support to their peers.

Roose said: “At its heart, it’s an approach about behaviour and social movement and change. We’re working to change the way that we think, we’re working to change the way that we deliver, manage and commission.”

The programme aims to improve quality of life and the experience of care while reducing cost. In its original form, two GP practices, supported by staff and volunteers from the community and voluntary sector, worked with 100 people deemed to be most at risk of hospital admission. They developed individual health and care plans, with patients’ own goals as the central focus, to see if this could reduce the dependency of the individual on public services and make the shift from unplanned to coordinated care.

The original cohort was a success and it was tested further in Penwith, where the programme demonstrated a change in the way services are delivered, with frontline teams voluntarily coming together and developing a new way of working based on respect for each other’s expertise.

It has since expanded even further and the next steps are to embed this learning into a new model of care in Cornwall, shaped around people and communities and focused on supporting people to live the lives they want to the best of their ability.

Dr Anderson, one of the original pioneer GPs, said: “From a clinician’s perspective, Living Well is about three important factors. It is about empowering patients; it is about creating that trusting and supportive and work environment; and it’s also about looking at risk and managing that at a community level.”

Harnessing the power of communities and data

Dr William Lumb, GP and chief clinical information officer at Cumbria CCG, told the audience at his session that clinical informatics will be the “essential enabler” of the NHS Five Year Forward View.

That vision requires that we grapple with the inherent complexity of care, the variability in performance of individuals and organisations and the challenge of how to harness the full power of communities, he argued. Indeed, health and social care economies are almost never designed in a way where function dictates form.

“We have to do better, we can do better and I will explain why we can, how we can and the tools we are using in Cumbria to start pushing this,” Dr Lumb said.

To get there he believes technology and software can be used to move the current models to a designed system without having to go through a big reorganisation or changing structures.

Over the past five years, Cumbria has been pursuing an ICT strategy that, at its core, seeks to “ensure technology is supported, timely, secure, accurate, useful, available and patient-centred to improve patient outcomes”.

This included creating an accessible patient record for both the clinician and the individual; data-sharing across services; improving network streams and ensuring there was a continuing cycle of improvement that was “all about outcomes”.

Dr Lumb said that data is an essential element of improving systems but that all elements of the economy; patients, clinicians and providers, must trust it.

What has gotten in the way of this for many years, and the development of clinical informatics, is the manipulation of figures.

He advocates for EPR (electronic patient record) data, which Cumbria has used in many of its projects, as this cannot be “manipulated” like other forms of data.

Clinicians spend most of their time navigating clinical information, he argued, and then having to navigate providers to provide the services once the information has been assessed. He believes this is time wasted that could be better spent on clinical activity.

End-of-life care

During an impassioned session on how partnerships can transform end-of-life (EOL) experience and care, Salli Jeynes, chief executive of EOL Partnership, said: “I’ve been to a few sessions this morning where we talk a lot about care pathways, but I’ve not heard much about when people don’t get better. There is a lot of talk about prevention and cure but we’re on the other end of that, really, supporting people who are going to end their lives.”

The EOL Partnership was set up last year and was formed from three existing work streams: Cheshire Hospices Education, Cheshire Living Well Dying Well and Cheshire End of Life Care Service Model. Its overall aim is to “transform end-of-life experience and care”, to create a more complete and holistic approach to living well, death and loss.

The Partnership covers the whole health economy in Cheshire, with partners including CCGs, trusts, local authorities, charities and academia.

Jeynes said: “The biggest thing about us, and our partners, is having a ‘common purpose’. It is about people agreeing to deliver their own agenda while also helping partners to deliver theirs, even if it isn’t in your interest.

“We also recognise that we have shared common humanity. This topic matters to all of us. How we live and die really matters. Mortality is universal.”

Specialised commissioning overspends led to ‘policy-paralysis’

At another session, delegates were told that budget overspends in specialised commissioning after the introduction of the Health and Social Care Act led to ‘policy-paralysis’ that left many patients in limbo.

John Murray, director of the Specialised Healthcare Alliance, said the Act did help clarify where responsibility lay for commissioning services, and it secured funding for prescribed services.

“It is good to have national specifications and commissioning strategies. But, it has to be said, a lot has gone badly,” he said. “There was a big budget overspend. This was, in part, because the budget hadn’t been properly calculated in the first place – the data provided by PCTs was largely not accurate; it was also due to extra activity by secondary care trusts; and the Cancer Drugs Fund (CDF) started to run out of control. Even last year, there was an overspend of about £220m in specialised [commissioning], more than half of that was due to the CDF.”

He added that this brought about “policy-making paralysis”. “Frankly, for a couple of years NHS England almost stopped making decisions. But, as a result, an awful lot of patients were left in limbo across quite a large number of services.”

Murray did argue that there is absolutely no reason why CCGs shouldn’t commission specialised services – they just need to be de-prescribed by ministers, with bariatric surgery being a case in point.

Discussing the longer term future of specialised commissioning, Murray said: “I find the Five Year Forward View an interesting document because it scarcely mentions commissioning, but it does talk about the wider role of delivering integrated care. There is, crucially, especially in terms of specialised commissioning, a lot of scope for better integration to be delivered by primary providers.”

The NHS still has a dysfunctional relationship with its estate – CHP

NHS buildings can act as a focal point to deliver and drive change at trusts across the country, but those in the health service still have a “dysfunctional relationship” with the estate, according to Antek Lejk, executive director and partnering lead at Community Health Partnerships (CHP).

He said there are lots of examples where high-quality buildings are not being used in the “right way”. Lejk, who for the past 20 years has worked mostly within the NHS, having run two NHS trusts and a primary care trust, said that money is always going to be a challenge, especially during austerity measures and rising demand, but things will need to be done differently to deliver future integrated models of care and savings.
He stated that taking a strategic approach is important in this work to deliver new infrastructure models and there is a great importance in getting the right leadership people together to develop, understand and commit to achieving a common outcome.

The Department of Health has just launched its Local Estates Strategy (more on page 37) and Lejk said that CHP will advise 96 CCGs and NHSPS will advise 114 on how best to deliver these strategies and services.

Dedicated teams from CHP and NHS Property Services will provide independent expertise with a real customer focus, understanding that different approaches might be needed in different healthcare systems. The aim is to help commissioners drive real value that leads to tangible improvements in the efficiency and effectiveness of the estate, making it fit for the future.

CCG members said they are struggling to see this leadership and support on the frontline – but Lejk said if the NHS doesn’t improve things and half its estate is empty, then its credibility is blown.