Clinical Commissioning Groups are now centre stage. Everybody is anxious to see them living up to the challenge of improving services at a time of flat or decreasing funds, ever increasing demand and massive changes to the basic organisational structure of the NHS.
‘Will they make it?’ is a £65 billion question I certainly cannot answer. I am convinced however that, to succeed, commissioners need to secure as much support as possible to make the hard decisions ahead, in particular from patients and carers, as well as managers and clinical staff in the NHS, the voluntary sector and the public.
Over the past eight years I've had the good fortune to work with LSE on the development of a decision support tool to help healthcare priority setting with local stakeholders. The Health Foundation has now launched it as Star (the 'socio-technical allocation of resources’), a user-friendly Excel tool with supporting material available free of charge. The tool helps to assess current and future health interventions in terms of their health benefits, value for money and in setting priorities for health in local populations.
Star also provides a structure for a conversation with local stakeholders in one or more workshop meetings. The conversation starts by identifying areas and interventions that seem to have scope to improve their value for money.
We developed and tested the process with three English PCTs, two local health planning authorities in Tuscany (Italy), in Ontario (Canada), and with an organisation of professionals in respiratory care (IMPRESS) in the UK. Further pilots in three PCTs/CCGs have tested the user-friendliness of the tool.
In the assessment of value for money, Star embeds health economic principles systematically in a simple and original way. Health economic principles are made accessible to non-specialists by breaking down the task into simple questions and then feeding back the answers with the support of visual aids.
The key questions asked are simple ones which healthcare commissioners should be able to answer:
- What does the intervention consist of?
- Who benefits from the intervention?
- How many patients will benefit?
- What would happen, in particular in terms of health outcomes, to patients if the intervention was not available?
- What happens to them, in particular in terms of health outcomes, with the intervention?
- How much does it cost to provide the intervention for our population?
Having seen Star work in practice, however, I found that these questions are in fact very difficult to answer because the NHS does not provide routine data on the impacts of interventions on the health of the population. Even randomised controlled trials, when available, need to be interpreted and adapted to the local population, which is usually older and with multiple morbidities.
Answering these questions often means that participants need to make heroic estimates. These will certainly be subject to error, but there will be an audit trail and making estimates explicit and open to challenge is, in my view, better than no estimate at all. In fact, a key learning of our initial research project was that the first approximate models we developed produced approximate results that were confirmed by subsequent more sophisticated models. This gave us the confidence to work with heroic assumptions.
The visual aids are very powerful for reflecting back the information gathered in the discussion to display impact on population health, on budgets and in improving value for money. The value for money is displayed with a triangle (see example below) that reports the total cost on the horizontal side and the population health benefit on the vertical side. Interventions with a good value for money will hence have a steeper ‘slope’.
It is helpful to have a facilitator at the workshops that is seen as independent, in the sense that he or she does not have a stake in the decision. The key outcome of the workshop is not so much the numerical results, but the discussion that comes about in answering the questions and the understanding that comes with making sense of the results. The role of the facilitator is fundamental to ensure everybody has the opportunity to contribute.
We also found that the process needs an internal leader to take responsibility. This leadership helps in engaging stakeholders meaningfully and in communicating clearly the logic of the recommended changes.
My hopes for Star are that it will become a really useful tool that people allocating healthcare resources for a population can use to think clearly, collaboratively and boldly about the services which are to be delivered.
I am sure there is scope to make Star even better and I am keen to hear your views on how to do so.
Mara is a Fellow, Research Officer and part-time PhD student in Management Science at LSE.