Deputy Head of Library Services, KnowledgeShare, Royal Sussex County Hospital, Brighton, UK
Received date: 22 September 2010; Accepted date: 23 September 2010
In July 2010 the newly elected coalition government of the UK published its White Paper on health and catapulted the National Health Service (NHS) into one of the biggest periods of uncertainty in its history. The scope of the changes outlined in Equity and Excellence: liberating the NHS is far-reaching and radical, and the fine detail is still emerging as I write. It is not yet clear to anyone quite what the healthcare landscape will look like once the dust has settled, but one thing seems certain: primary care staff are set to experience the greatest disruption.
NHS clinicians reading this at work now find themselves sitting in the very headquarters of the health service as responsibility for commissioning high-quality care transfers away from the Department of Health, strategic health authorities and primary care trusts (PCTs) and into clinics and consulting rooms up and down the country. It will be the responsibility of ‘every GP practice to ensure that taxpayers’ money is used to achieve the best possible outcomes for patients’ (p.11), with only a small NHS Commis-sioning Board to support them and hold them to account.
The intention of the Government is that by April 2013 a national collection of general practice con-sortia, from which no practice will be excluded, will have taken full financial responsibility for commis-sioning. Responsibility for public health improvement will have transferred to local authorities and PCTs will have been dissolved. General practitioners (GPs) will be leading collaborations between local government, social care and providers of acute, community and mental health care to deliver integrated patient path-ways across their patch, and only community phar-macy, optometry, maternity and specialised service provision will be outside their purview.
Since the publication of the White Paper the proposed changes have been explained, explored, analysed and intently debated. Countless news media, think tanks, professional associations and arms-length bodies alike have weighed in with their thoughts, and more opinions and reflections are published every week. Some of the most useful sites to be aware of include those of independent think tank the King’s Fund (www.kingsfund.org.uk/current_projects/the_ nhs_white_paper) and the independent membershipbody the NHS Confederation (www.nhsconfed.org/ Key-Health-Issues/Health-white-paper). A large num-ber of responses from different organisations have been gathered by NHS Evidence at www.library. nhs.uk/healthManagement/page.aspx?pagename= WHITEPAPER.
One of the biggest questions raised by the White Paper concerns just how ready and willing GPs are to take on the commissioning role. The White Paper identifies demographic analysis, contract negotiation and financial management as a few of the new activi-ties that GPs will be required to take on, or to employ others to do for them. The King’s Fund points out that for most GPs the learning curve will be exceptionally steep; the skills required to manage large budgets and assess population needs are a world away from the core attributes of the profession. There will be con-siderable anxiety and a large knowledge gap.
Over the coming months the Department of Health and the new NHS Commissioning Board will be developing documents and new online resources to support the thousands of newly minted commissioners. In the meantime there are already a number of websites devoted to illuminating the commissioning process and providing tools to support the purchase of high-quality patient care. These sites will be the topic of the next two editions of KnowledgeShare Web Alert, with this first issue focusing on professional networks for commissioners, overviews of commissioning re-sources and some opportunities to find evidence of what works to improve health care.
Networks to support commissioners
Many general practice staff just beginning to grapple with the complexities of commissioning may wish to begin by seeking out connections with other profes-sionals from across the country who can share advice and best practice. PBC Connection (pbc.networks.nhs.uk) was set up by NHS Networks to bring together staff interested in practice-based commissioning (PBC). This collaborative network is independent, inclusive and eager to draw in existing PBC networks under one umbrella in order to stimulate debate and spread successful ways of working.
Selecting ‘Resources’ followed by ‘Regional Resources’ from the tabs at the top of the page gives access to a number of more localised PBC networks. This section of the site also gives access to maps of stakeholders which include small biographies of clinical champions for PBC according to where they are located in the country. Contact details for many existing GP clusters are included in the stakeholder maps.
The ‘Resources’ section of the website is also used by members of the network to make available toolkits for commissioners, lists of support organisations and an extensive collection of ‘good practice’ documents, including business cases, commissioning plans and governance arrangements.
In addition, there is a regularly updated blog con-taining opinion pieces from a wide range of PBC stakeholders, including plenty of discussion of the changes outlined in the White Paper and a discussion forum on which members of the network can discuss areas of shared interest.
Exactly how GPs will collaborate with other primary care professionals to commission NHS services is one of the many questions still to be answered following publication of the White Paper. Needless to say, there are countless nurses, pharmacists, dentists, optometrists and other allied health professionals eager to be involved in any commissioning decisions, and the Healthcare Professionals’ Commissioning Network has been created in order to give them a voice(ww.networks.nhs.uk/nhs-networks/healthcare-professionals-commissioning-network).
The Network’s message is that in order to meet the Government’s challenge to improve quality and productivity outcomes, a multidisciplinary approach must be taken to the planning and delivery of care. Its aim is to break down the barriers between professions and raise the profile of non-medical contributions to the commissioning of care. The network recruited 100 members in its first two months and the number continues to grow. The website provides the oppor-tunity to share resources and to make connections with other staff interested in this cross-professional approach.
Gateways to commissioning websites
With UK health care in such a state of flux, the next challenge for GP commissioners after making some connections with colleagues around the country will be to stay abreast of the changing national picture. Not only are new guidelines, briefings, reports and tools being published at an accelerated rate, but the national organisations that support and advise healthcare staff are waxing and waning as well.
The NHS Institute for Innovation and Improve-ment (NHS III) will soon be disbanded, although it is hoped that many of the resources it has developed will still be available. However, a new NHS Commis-sioning Board is then to be launched, which will come with its own set of model contracts and commission-ing guidelines. Local Involvement Networks (LINks) are out, but HealthWatchUK will soon replace them. The Health Protection Agency will be abolished, but the role of the National Institute for Health and Clinical Excellence (NICE) will be extended. The following websites aim to keep track of who is coming, who is going and what documents relevant to com-missioners are being published.
NHS Evidence Commissioning Specialist Collection
Managed by the King’s Fund’s Information and Library Service, the Commissioning Specialist Collection from NHS Evidence provides regular updates on the latest information resources relevant to commissioners in health and social care. Newly published documents are pre´cised and appraised by the team and then distributed to users via a constantly updated RSS feed or a monthly email alert. Resources and events from a large number of national and international organis-ations are identified, ranging from the Association of Public Health Observatories to the World Health Organization, and their selection criteria are made available in a content development strategy.
Once this information has been distributed, the Commissioning Specialist Collection then stores the links, along with their short summaries, in an ever-expanding, fully searchable database. This library of resources can also be browsed by topic, under head-ings such as ‘types of commissioning’ (practice-based, joint, specialist etc.), ‘commissioning competencies’, ‘disease groups’, ‘legal and technical’ and ‘knowledge and skills’ (communication, market management, decision making and so on).
Forthcoming events and conferences, journals that cover the topic of commissioning in health care, and lists of toolkits and data sources are also available from the home page.
Finally, the Collection team also writes its own ‘key topics’, which are overviews of particular commis-sioning issues that have been suggested by stakeholders. For example, the key topic on ‘social enterprise or-ganisations’ contains a definition, including selected quotes from the Department of Health, a range of guidance and tools, a section on additional resources and a list of press releases and media coverage. The overview also identifies a number of articles and parliamentary reports relevant to social enterprise.
The Commissioning Handbook (https://commissioning.pbworks.com,), although originally intended to sup-port NHS library and knowledge staff who are pro-viding information to commissioners, will also be of considerable use to commissioners themselves. The Handbook is a wiki, which means that it is set out as an online book – there is a contents page in the sidebar on the right – but it is collaboratively produced and regularly updated. It was originally devised by Quality: MK, a Milton Keynes-based collaboration between the local PCT, practice-based commissioners, the Milton Keynes LINk and the Centre for Evidence-based Medi-cine in Oxford, and has been developed by library and knowledge service professionals from across England.
After an introduction explaining what the Hand-book is for and how to contribute, the second section focuses on policy and keeps track of Government papers and consultations as they are published. Inde-pendent commentary and analysis is also listed, along with Government responses to consultations. Other sections focus on providing links to leading support organisations, rather than simply listing their publi-cations. For example, Section 3 on ‘engaging with partners’ links out to NHS Networks and the Patient Information Forum, which are both key enablers of collaborative commissioning.
Each section provides tips on how to get better results when searching Google for commissioning-related topics, and the Handbook is peppered with links to case studies and tools. These include a report on how the Isle of Wight has used a value-for-money approach to setting local priorities, a list of interven-tions with limited value that will aid in decommis-sioning and a health promotion toolkit from County Durham and Darlington PCTs. Section 7 is worth particular attention as it lists information resources according to priority areas (Tier 1 and Tier 2), specific populations (children, older people, people with dis-abilities etc.), specific diseases and specific service sectors (such as community care or urgent care).
Further items on commissioning may be picked up by subscribing to the horizon scanning updates produced by the Library and Information Health Network North West (LIHNN; www.lihnn.nhs.uk/lihnn-publicarea/ horizonscanning). There are currently 17 bulletins onvarious health topics, including alcohol, dental health, diagnostics, obesity and stroke. They include not only national publications such as guidelines and audit reports, but also noteworthy articles from clinical and health management journals.
The notifications describe the information re-sources in brief, giving the date of publication, author and length, and link to the full text of the document where it is available. Notes on what passwords may be required for full text access, and how to get hold of them, are also given.
Evidence of best practice
The White Paper establishes ‘improvement in quality and healthcare outcomes as the primary purpose of all NHS-funded care’ (p.21), so questions about what works to improve the quality, safety and cost-effec-tiveness of health care remain paramount for com-missioners. Many of these questions have already been answered by NICE, and the role of NICE is expanding. The organisation has been asked to develop 150 new quality standards by 2015. However, the number of questions that can be answered by NICE is necessarily limited by time and resourcing, while the number of questions that commissioners will have is not.
In order to ensure that they always have the best evidence to inform their decision making, GP com-missioners must learn from their colleagues in PCTs and acute and community services and make use of the excellent network of NHS Library and Knowledge Services that already exists to ensure practice is evi-dence based.
NHS Library and Knowledge Services have the potential to save commissioners and their teams considerable time and money by searching for and delivering research evidence and best practice. Some additional resourcing will be required, but the money saved by not engaging private consultancy firms and instead making use of the existing expertise in NHS-related information retrieval has already convinced many commissioning teams to begin forging these links.
The managing director of Health:MK, the practice-based commissioning organisation that involves 26 of the 27 GP practices in Milton Keynes, talks about their ‘systematic approach to service development’ that includes ‘the appointment of ... commissioning librar-ians who have provided new skills and timely support to the commissioning process.’ These commission-ing librarians bring together the resources needed by groups involved in pathway review and redesign, synthesise the evidence and signpost commissioners towards new information in their areas of interest.
A presentation on the work of the Quality:MK group(https://commissioning.pbworks.com/f/MK+Case+study+BCG+June+2008+AG.ppt) shows how com-missioning librarians can work alongside staff in health intelligence, contracting and public health, as well as with patients and representatives of the volun-tary sector, to ensure that all forms of ‘evidence’ are fed into the process of service redesign.
To make links with your own local NHS Library and Knowledge Service, use the Health Library and Infor-mation Service Directory (www.hlisd.or).
Map of Medicine
The Map of Medicine (https://england.mapofmedicine.com), an online patient pathway tool, was firstlaunched in 2004 and has been slowly building up an NHS user base ever since. The concept behind the system is novel and potentially groundbreaking, but full implementation of the system does require an investment of time and money on the part of local NHS organisations. The system presents algorithms of care, taking patients from first presentation of symp-toms, through the GP consultation and on to referral and treatment in hospital or the community, as appropriate. What makes it innovative is that there is the facility to alter these pathways and adapt them to reflect local services. In this way the map becomes a commissioning tool, an opportunity to direct the flow of patients through the system.
The Director of Commissioning at NHS Wirral, who has been using the Map of Medicine since 2007, explains that the Map ‘provides a common language between clinicians and managers’ and that it has transformed the way that services are provided in the area. The Map has, for example, significantly increased the number of chronic obstructive pulmon-ary disease (COPD) services that are being provided in the community. At NHS Brighton, the author has been involved in work using the Map as a means of streamlining GP referrals and hosting a ‘service map’, showing all acute, community and mental health services in the local area by disease area. This work prevents inappropriate referrals, thus saving time and money.
In addition, the Map has recently launched a new feature providing specific recommendations to im-prove productivity. This additional guidance is cur-rently attached to the diabetes and COPD pathways (but will be produced for other pathways over time) and is aimed at commissioners and staff in health improvement. The guidelines direct users towards evidence-based opportunities to improve cost effec-tiveness. The diabetes productivity considerations can be found online at www.mapofmedicine.com/Global/ pdf/productivity_considerations_Diabetes.pdf
NHS Evidence – QIPP
The Commissioning Specialist Collection from NHS Evidence was mentioned above as being a useful portal to a wide range of commissioning websites. Another useful subsection of the NHS Evidence website is the QIPP collection (www.library.nhs.uk/qip), which allows local NHS teams to record their own case studies demonstrating how they are improving quality and productivity. This database of best practice from across the UK is small but steadily growing, and covers patient pathways from areas including acute care, planned care and long-term conditions. There are also best practice case studies related to procurement, medicines management, safer care and other work streams. These examples are less rigorous than pub-lished research projects, but can be very helpful in moving beyond the question of whether an inter-vention works, to how one can successfully implement it in practice.
This article has identified a number of websites that will be useful for commissioners looking for ways to make contacts around the country and remain up to date with the latest national guidance and national reorganisations. It has also looked into a number of ways of finding out what works to improve product-ivity, effectiveness and safety in health care, whether that information comes from published research evi-dence or examples of best practice.
Part two of this article will go on to identify a number of online resources that will allow commissioners to interpret local data and compare it against national outcomes. A range of organisations that provide specific tools to support needs assessment, contract implementation, performance management and pro-curement will also be covered.
Thanks to Judy Lehmann, Head of Library Services at Brighton and Sussex University Hospitals NHS Trust for her contributions.
Commissioned; not externally Peer Reviewed.