Quality in Primary Care Open Access

Introduction

Modern political and economic pressures, combined with changing population needs and expectations, require the NHS to commission new and innovative health services. The success of this policy hinges on NHS managers and professionals rapidly developing the skills and experience essential to commission innovative yet affordable service specifications that meet the needs of patients, the NHS and the public.

Conscious of the need to build local commissioning capacity, we set out to identify ways in which we could support our own colleagues to commission new services. We identified some key tools, reports and websites which we passed on to our colleagues, but we were concerned that these resourceswere largely theoretical or conceptual and did not include the practical advice that we considered essential. We have more than 20 years of experience in commissioning, and recognise that the process can be very challenging for the inexperienced or unwary.

On the basis of our experience, we developed our own guidelines to help our colleagues succeed as effective and efficient commissioners. The guidelines outline the key stages and action points within the commissioning process, and emphasise how to avoid potential pitfalls.

In order to provide further support for our colleagues, we also provided them with opportunities to commission new services and acted as mentors to support their own reflective practice.

Our experience demonstrated that the following resources were most useful for colleagues seeking to develop their commissioning skills and knowledge.

Resources

Health needs assessment: The epidemiologically based needs assessment reviews www.hcna.radcliffe-oxford.com

This series, funded by the Department of Health/ National Institute of Health and Clinical Excellence, is compiled and managed in the Department of Public Health and Epidemiology at the University of Birmingham.

This extensive evidence-based series provides epidemiological evidence for a wide range of diseases, service areas and specialties. In each instance it summarises, for an average health district, the target population, the services currently provided, the evidence of the effectiveness and cost-effectiveness of those services, and the optimum configuration of services.

Although first published in 1994, the reviews have since been updated and extended and represent the definitive health needs assessment text. Authors Stevens and Rafferty are recognised as experts and leaders in the field of epidemiological health needs assessment.

This website also features an excellent introduction and overview of health needs assessment. The reports are also available in print as:

. Stevens A, Raftery J, Mant J and Simpson S. Health Care Needs Assessment: the epidemiologically based needs assessment reviews. Oxford: Radcliffe Publishing, 2004.

Also see:

. Bradshaw JR. The conceptualisation and measurement of need: a social policy perspective. In: Popay J and Williams G (eds) Researching the People’s Health. London: Routledge, 1994, pp.45–57.

. The Gateshead Centre for Enabling Health Improvement www.cehi.org.uk/health_needs_assessment, which features a collection of locally developed resources for undertaking health needs assessment, as well as teaching resources, references and reports.

NICE, the National Institute for Health and Clinical Excellence, has two guides on health needs assessment available online (www.nice.org.uk). Both were in practice developed by its predecessor body, the Health Development Agency (www.nice.org.uk/filtercatisbn.aspx?o=hda.publications). The first, The Health Needs Assessment Workbook, provides an extensive step-bystep guide for undertaking health needs assessment, and provides a useful model process, but one which would be resource intensive in implementation. The second, Health Needs Assessment: a practical guide was published by NICE in 2005. There has been significant improvement between these editions, and the inclusion of reports of practical experiences are particularly welcome. Health needs assessment is still described as a five-stage process, each with its own substeps.

The National Library for Health (www.library.nhs.uk) features a number of specialist libraries including health management. The health needs assessment briefing (Powell J. Health Needs Assessment: a systematic approach. Compiled March 2006, www.library.nhs.uk/healthmanagement/viewResource.aspx? catID=4033&dg=59&offset=10&resID=29549) is one of many helpful management briefings in the health management library (all briefings are catalogued alphabetically). It provides an excellent overview of the HNA process and links to other resources.

Resources for commissioning

The National Association of Primary Care Trusts’ Commissioning Friend (www.natpact.nhs.uk/cms/19.php) has lots of resources with practical steps for all stages of the commissioning process, but the resources are all distinct, do not offer a coherent stepwise guide for individuals to follow, and are more focused on whole-system change rather than realising services.

The NHS Commissioning Framework (www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4137226&chk=D2YSig) lays out the principles, approaches and model approaches to commissioning in the NHS, and outlines the regulation of the commissioning process for the coming years.

Many resources have recently been drawn together by NHS networks (www.networks.nhs.uk/166.php), which contains a helpful bibliography of resources.

Among the academic reviews of commissioning, the Health Service Management Centre’s analysis, commissioned by the NHS Alliance (www.networks. nhs.uk/uploads/dm/commissioninginthereformed nhs.pdf) is the perhaps the most interesting. While it contains a list of principles to follow, it also helpfully includes some testament to local practice.

Finally, the Health and Social Care Change Agent Team (CAT) (www.cat.csip.org.uk/index.cfm?pid=359) provides advice and support on a wide range of issues that affect the care of older people and has work streams focusing on commissioning.

CAT has developed an e-book that will help commissioners to find reliable information and support to help them develop their practice. The ebook pulls together contemporary thinking in the form of papers, case studies, a glossary and a comprehensive resources section. The introduction provides a helpful overview of commissioning.

We have supplemented this by providing a practical guide, based on our experiences of commissioning, and supporting individuals through their development (https://www.cehi.org.uk/06_health_topics/training_and_development).

Practice-based commissioning

Tools and support for practice-based commissioning are currently evolving rapidly. The following two sites pull together essential tools, guidance and support and reflect current best practice and experience in this area.

The Primary Care Contracting website: www.primarycarecontracting.nhs.uk/ 99.php

This has been developed by the Department of Health and the National Primary and Care Trust Development Programme (NatPaCT). It brings together a range of information and tools about the new primary care contract and includes links to other useful sites and resources. It has a whole section devoted to practice-based commissioning (PBC), which features a preliminary PBC toolkit, links to Department of Health guidance on PBC and a range of examples to support various aspects of implementation.

The toolkit was published in April 2005 and is designed to be used in conjunction with the Department of Health guidance. It includes simple ‘checklists’ providing helpful starting and discussion points.

Department of Health website: www.dh.gov.uk/PolicyAndGuidance/OrganisationPolicy/Commissioning/PracticeBasedCommissioning/fs/en

This features a section on commissioning, with a subsection on PBC. The PBC section features the guidance, essential tools and templates and includes updates and frequently asked questions as well as case studies and links to other resources.

Conclusion

The resources we have identified form the basis of a capacity building programme for health service managers and professionals. They focus primarily on the concepts, theories and rules that underlie commissioning in the NHS.

However, best practice in adult education indicates that the learning experience is strengthened when theoretical and conceptual approaches are accompanied by opportunities for practical experimentation and reflection.

Our local experience suggests that these resources alone are inadequate. They need to be supported both by practical guides and the opportunity for practical experience and reflection, which enables rapid development of both confidence and skills as commissioners.

We recommend that NHS programmes to build capacity for commissioning should use these resources, but these should be supplemented by learning based on practical experience and opportunities for reflection.