Outcomes-based commissioning is all the rage in the NHS. Many clinical commissioning groups (CCGs) are seeing it as currently the only viable commissioning route to deliver on the vision set out in the Five Year Forward View; 2014’s HSJ ‘CCG barometer’ showed three-quarters of the 109 CCG leaders who participated thought it was likely or very likely they would re-contract a significant amount of spend under an 'integrated' contract covering a defined population.
Hang on. Let’s rewind. What are we talking about? ‘Outcomes-based commissioning’ describes an approach to health care commissioning based on outcomes (unsurprisingly), but also the use of a population approach, metrics and learning, payments and incentives, and co-ordinated delivery across providers. It’s these five components together which make up the concept – as such ‘outcomes-based commissioning’ can best be thought of as a brand name rather than simply a description.
So is it the panacea we’ve been looking for? A lot is said about international examples of success with the ‘Alzira’ model used in Valencia being oft quoted by Jeremy Hunt as something the NHS should be moving towards. Colossal claims abound: McKinsey have forecast a saving of ‘a trillion dollars’ in the United States over the next decade for the successful roll-out of an outcomes-based payment model in government health care spending. However if you dig a bit deeper you find that the evidence for outcomes-based commissioning reflects its relatively recent history in health care; while evidence exists, it is limited in scope and strength. And certainly in England, there are as many cautionary tales as there are success stories.
Having recently joined a CCG in a role leading the development of new models of care, outcomes-based commissioning on the face of it certainly seems an attractive prospect. It is almost impossible to disagree with the aim to move from a system focused on process measures and targets to a system that is focused on improving the outcomes that matters to citizens and patients. It also offers a real way to overcome one of the major stumbling blocks to wider integration – the perversity and misalignment of current payment mechanisms to NHS providers – offering the opportunity to incentivise providers to work together and find more innovative, high value and cost effective solutions to care that focus more on out of hospital care, preventative services and self-management in order to deliver within a fixed budget.
However as much as the potential opportunities that outcomes-based commissioning offers are clear, it is equally as clear that this is not necessarily an easy path to pursue.
In our report, Need to nurture: outcomes-based commissioning in the NHS, we have suggested how national policy needs to support and nurture the development of outcomes-based commissioning. As a commissioner who is considering going down this road, I think there are three areas that local areas really need to contemplate before pursuing such an approach:
First, CCGs need to recognise that doing this requires a different skill set – many of which they probably don’t have in-house. This includes a high level of expertise in public engagement; use of data and analysis to understand both patient behaviour and enable a deep understanding of population need; and to understand the deployment of resources to be able to make proper actuarial assessment of risk, present and future; and develop true outcome measures rather than just proxies. This should not be embarked upon until commissioners have recognised and sought to develop or have access to the capability required to deliver this successfully. One of the over-riding messages I have taken away in talking to those who have already embarked on this journey is that it has been significantly more complex and has taken significantly more resource that they had expected.
Second, much of the discussion out there about outcomes-based commissioning is actually focused on the different contractual models and mechanisms – such as the relative benefits of a prime provider model vs the use of alliance contracting. Whereas as commissioners we know that the process of planning, securing and monitoring services is as much a social process as it is a technical one. The key to delivering this sort of transformational change doesn’t lie in the contractual change, which although a powerful tool, cannot deliver if it is not accompanied by strong local will and shared vision of change from clinicians, managers and local politicians. Commissioners should not underestimate the time and continual effort that will be required to form and maintain local partnerships and develop the strong and trusting relationships required for success.
Third, we can see that many of the examples such as Alzira that have implemented an outcomes-based commissioning approach and have demonstrated improvements in quality, outcomes and cost savings, have undertaken a holistic approach to quality improvement and transformational change. With the maturity of other system interventions, such as IT infrastructure and the development of capability and skills, being as important as the system change itself. This is backed up by wider evidence in the large scale change literature – that improvement activity in isolation is not enough; transformation requires comprehensive change management activities in concert with institutional culture change and unwavering committed leadership.
This leaves me wondering do the majority of CCGs with tightening running cost allowances and significant challenges in delivering on the day-to-day, have the headspace, capacity and capability to take forward outcomes-based commissioning in the short-term? And I guess the question I keep returning to is, can we afford not to?
Clare is a Senior Policy Adviser at the Health Foundation and Head of Primary Care & Community Development, Horsham & Mid Sussex and Crawley CCGs www.twitter.com/clareahealth
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