Centre for Primary Health Care and Equity

Primary Health Care Commissioning

Mark Harris.

Overview of presentation

• What is commissioning?

• What forms of commissioning are effective?

• What are the requirements for implementation

• How can commissioning address equity?

Service & contract design

Contract implementation

Provider development

Resource & risk analysis

Strategic plan / commissioning

pipeline

Procuring Services

Monitoring and Evaluation

Strategic Planning

Assessing needs & market capacity

Managing performance

Managing contracts

Supporting patient choice

Patients / Public

Commissioning Cycle

Definition:The process of planning, purchasing and

monitoring services for • a population

• subpopulation • individual client

Australia• PHN, NSW NGO contracts,

NDIS, HACC

• Most population level and primary (except MLs largely secondary)

• Breadth of activity: Mental health, drug and alcohol, allied health, afterhours, specific population groups

Overseas• NZ DHBs, UK PCTs and

CCGs, Germany/Netherlands Health Funds, US PPO and ACOs, Finland Municipal.

• Most population or individual, primary and secondary,

• Broad or specific service provision

Commissioning: levels, types, breadth

What forms of commissioning are effective?Level Study citation Service use Quality of care Outcomes Value

Individual Ly DP, Glied SA. 2014;29USA Managed Care

Managed care physicians have higher income and spend more time in patient care, modest costs on time outside patient care and have lower perceived adequacy of time with patients

Salmon et al 2012 USA Accountable Care

A shared savings accountable model of care with collaborative support from a payer can reduce costs and improve quality.

Sub-population

Barnes, K et al (2013). UK PCTs

Reduction in emergency admissions for children

Goldman 2010UK Clinical

Commissioning Group

No change in length of stay, hospital admission, delays in transfers of care

Population McLeod, H., etal 2015UK Primary Care Trust

PCTs achieved increases in number of 4 week quits per 1000 adult population of 9.6% compared to 1.1% in control group PCTs. The largest 2 of 10 providers accounted for these increased quit rates. 3 of the 10 were new market entrants

Dusheiko et al 2006 UK Fundholding

Patients of fund holders had decreased emergency admission by 3.5% and elective admissions by 4.9%

Freeman and Peck. 2006UK joint commissioning

Users and carers were largely positive towards the provision of specialist services under a mental health partnership

? Reduced admissions

Consumers positive

? Improved outcomes

? Cost Savings

What are the requirements for implementation?

Processes of Commissioning

National Local

Planning Workforce planning for more flexible workforce (Ham 2008)Integration requires some flexibility about competition and separation of purchaser and provider (Newman M 2012)

Clarity over roles and responsibilities and supportive legal frameworks particularly in the context of pooling or flexible use of budgets and joint commissioning (Newman M 2012).

Need good information on pattern of care, quality, cost of services (Newman M 2012)

Need to engage and involve patients and clinicians (Sampson F 2012)

Ensure widespread uptake to prevent inequities (Mannion R 2008).

What are the requirements for implementation?Process of Commissioning

National Local

Contracting Providers need autonomy to respond flexibly to contracts (Ham C 2008)

Consumers need choice protected in contracts or regulation (Ham C 2008)

Need capitation and incentives that align with the aims of commissioning (Dickinson H 2015).

Competition law at odds with cooperation and relationship development (Ashton T 2004)

Need to have or develop management, technical and financial capability and stability of staff to implement commissioning (Figueras J 2005)

Need time to develop relationships and engage community and clinicians in contract negotiations (Ham 2008)

Integrated delivery facilitated by collocated teams and conterminous boundaries (Newman M 2012).

Need to develop a market which sustains the supply of service providers (Dickinson 2005).

What are the requirements for implementation?Process of Commissioning

National Local

Monitoring Focus on accountability of providers for both cost and quality including patient outcomes and reduce inappropriate care (Ham 2008)

Need common performance and outcome measures (USA, UK) (Guterman, Zezza et al. 2013)

Need consumer monitoring e.g. “Healthwatch groups” within quality commission (Newman M 2012)

Requires good data systems to monitor performance measures at local level (Robinson, Dickinson et al. 2012)

Principle1. To address inequities

commissioners need to be able to identify them within the populations they serve.

2. Commissioners need to be accountable for delivering equity.

3. There needs to be capacity for service provision and use in disadvantaged communities

4. Equity needs to monitored and evaluated.

Practice (UK CCGs)*1. In UK structural barriers separate

capacity for data collection and analysis separate from commissioners

2. CCGs accountability not clear.

3. Priority may be given to services and populations which use services. Disadvantaged groups underuse services relative to need especially if other constraints eg mental health

4. Limited measurement of impact on equity of access to health care

Commissioning for equity

* Wenzl Commissioning for equity in the NHS: rhetoric and practice. Br Med Bull 2015.