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UNIVERSITY OF BEDFORDSHIRE FACULTY OF HEALTH AND SOCIAL SCIENCES M.Sc. PUBLIC HEALTH HEALTHCARE COMMISSIONING MODULE UNIT CODE: PUB 012-6 MAY 2013 Table of Contents INTRODUCTION 3 BACKGROUND 3 CRITICAL APPRAISAL 1 5 Scenario 5 Strengths 6 Weakness 7 LESSON`S LEARNT 7 CRITICAL APPRAISAL 2 8 Scenario 8 Strength 8 Weakness 9 Lessons learnt 10 CONCLUSION 10 INTRODUCTION This paper is written as a finale module assessment; it aims to critically appraise two student healthcare commissioning posters in order to explore the content by providing the strength and weakness of the poster. It will assess how the content evident in each poster can be applied towards a real health care commissioning service and examine the important theoretical and practical aspects of the health care commissioning process which have not been included in each poster. The posters will be critically appraised using the East midland framework for regional commissioners, World class Commissioning principles and the Royal college of General practitioners. However, the paper will describe the concept of commissioning in health care and the frameworks will be briefly defined and described. This will entail a degree of significant evaluation skill necessary to be demonstrated as a Masters Student in Public health. ABBREVIATIONS: World class commissioning (WCC), Royal College of general practitioners (RCOGP), Department of health (DoH), Developing intelligent commissioning programme (DICP), Primary care trust (PCTs). BACKGROUND Commissioning can be described as a process of ensuring care services are provided effectively and they meet the needs of the targeted population and the community (DICP, 2011). However, Commissioning is a broad concept with different definitions; however it has been defined by the department of health (2007), “as a way of securing the best value for local citizens. It is the process of translating aspirations and need, by specifying and procuring services for the local population into services which deliver the best possible health outcomes, promote health equality and achieve this within the best use of available resources”. Health is mostly described as the absence of disease but to the commissioners it is described as the physical, psychosocial and socioeconomic well being and the need to join forces across the public sector (Cavanah and Chadwick, 2005). According to the World health Organisation (2013), factors that can affect the health of an individual or the community are; level of education, the environment and genetics among many others. Effective and efficient commissioning will benefit people in communities where there is a challenge in acquiring good health service due to some Socio- economic factors such as poverty, unemployment, access to health services. Furthermore, as a result of childhood mortality and life expectancy, all government departments are devoted to closing existing gaps between the most privileged sections of the society and the least privileged (Cavanagh and Chadwick, 2005). There is a need for effective commissioning to promote the health of the people and the community at large. The WCC is a statement of purpose developed by the (DoH) (2007), it aims to raise ambitions for a new form of commissioning that has not yet been developed or implemented in a comprehensive way across any of the developed healthcare economies (DoH, 2007). This programme was launched in response to the significant improvement in the effectiveness of delivery commissioning. Similarly, it’s essential for the World class commissioning PCTs to develop the knowledge, behaviour, skills and characteristics that underpin effective commissioning and these competencies are described using 11 core headlines to develop the knowledge and skill for effective commissioning (DoH, 2007). Essential steps required for an effective process of health care commissioning is shown in the figure below. Figure 1: World class commissioning cycle (NHS Information gallery, 2011). According to the Royal college of General practitioners (2010), a good heath care commissioning should be based on a good foundation which includes; improvement in the health outcomes for patients and community by understanding the specific health needs and priorities. This should be accessed in an evidence based approach in designing the services and monitoring its outcome. They should be empowered and supported to care for themselves and be involved in the commissioning process. Finally the commission should be committed to sustaining the use of resources, NHS finances, and the spirit of the staffs as well as time management. (RCGP, 2010). A competency framework was commissioned by RCGP for use by the clinical commissioning groups and outlines how commissioner`s can be effective and competent. the framework outlines that commissioners should act as a leader with a purpose and a clear focus and goal, should lead a consortium (a group of people coming together with the objective of participating in a common activity to achieve a common goal), serve a community by partnering with patients and public, evaluate the population needs, protect and promote health, leading commissioning by designing contracts and identifying gaps in service provision. Finally, the RCGP framework requires commissioners to lead improvement and innovations by promoting research and development and continual quality improvement (RCGP, 2010). CRITICAL APPRAISAL 1 Scenario This poster is a hypothetical commissioning development of a group of nurses working in a clinic in Newham hospital, following the increase in the prevalence of diabetes Type 2 in a remarkable number of teenagers and the young adults (16- 25) years in the borough of Newham, known to be associated with obesity and overweight, making the area to have the highest prevalence of T2DM in the united kingdom. However, in order to reduce the prevalence rate which were stated to be 3 to 4 times the national average. A programme was commissioned named the race against diabetes (RAD). This programme aims to increase the awareness of the risks, ensure wholesale changes in lifestyle, improve self management among young adults with diabetes type 2 and improve access to services. A health need assessment was conducted using a focus group and questionnaire. The result acknowledged the fact that they had poor eating habit and less physical activities among many others. A consortium was formed which entails various partners such as the school nurses, the parents, teachers, school boards and the local general practitioners. Terms of the contract were drawn and a budget of 2.5millin pounds was stated in the poster to be needed. Using a restricted procurement process, an invitation was advertised within a local newspaper and council webpage. The bid was won by diabetics UK and a 5 year contract was drawn. A midyear evaluation was conducted and monitoring was done to ensure the service commissioned is of high quality and sustainability. After a year the contract was evaluated to access the level of knowledge of the awareness of T2DM. Strengths According to WCC framework, commissioning is a cyclical process with 3 main stages which are the planning, procurement and monitoring. The poster illustrates an understanding of the three main stages of the commissioning process. The cornerstone of healthcare commissioning is to put the needs of the users first and ensuring that they are engaged and consulted because commissioning is directly linked to patient outcomes (East midland framework, 2007)). Similarly, according to (Hooper and Longworth, 2002), a health need assessment starts with a population defined by the same socio- economic status, creating a programme which will improve the health and reduce inequalities. In accordance to this, a health need assessment was conducted explicitly. This was carried out to generate a clear understanding of the views of the users and their needs were considered. However, there were a clearly stated aims and objectives. Following this, a consortium meeting was formed and highlighted the need to work in partnership based on principle 4 which states that commissioners should work in partnership to maximise effectiveness and reduce barriers to services, this enables a commissioning approach that facilitates discussions on strategies to achieve a common goal (East midland framework, 2007). In the meeting arguments were resolved using the conflict resolution model which emphasizes on de- escalating conflict by making appeals and doing what is said will be done without making threats (Grupta, 2011). In commissioning a service the commissioner will decide how to obtain a service by identifying a supplier within an environment of open competition to deliver best service (DoH, 2007). Similarly, a restricted procurement process was used to decide how to obtain the service and highlighted the importance that it improves manageability. A midyear evaluation and monitoring was done to ensure the service commissioned is of high quality which is in line with the WCC framework. The poster highlighted the principle 9 of commissioning which involves commissioners to monitor and evaluate performance Weakness In conducting the health need assessment, the poster indicated the use of questionnaire and focus group in assessing their needs, however there was no indication of how ethical considerations were met. In carrying out such activities on human participation, it is important to abide to ethics to ensure that participant’s right is preserved. According to Parahoo (2006), Ethical consideration ensures the reliability and validity of a study. Ethical committees or the institutional board must consent to the research before it can be carried out, because their role is to ensure all ethical principles are applied and to ensure informed consent (Parahoo, 2006). There was no indication of how this was achieved. The commissioning process in this poster did not highlight one of the overarching principles of procurement (Transparency), which states that a good practice in commissioning is to provide feedback to unsuccessful bidders and to allow sometime between notifying the contract award decision and executing the contract (DoH, 2010). According to the WCC framework, in monitoring the activity and quality of the service, feedback on data should be shared transparently across partners and should be used to feed into assessment of health needs of the local population. This framework also requires the need for patients to receive high quality information to assist them in making informed choices. However, a monitoring and evaluation was done but no indication of how this was met. LESSON`S LEARNT In conducting this critical appraisal, on a student perspective, understanding the health status and the health needs of the teenagers and young adults in Newham with type 2 DM has enabled me to understand the basic steps and importance of assessing the needs of a community. Commissioning is a continuous process that involves various principles and competences that should not be overlooked by every commissioner to achieve an efficient and effective commissioning. For example, a consortium was formed indicating the need to work in partnership to emphasize effectiveness in providing the service needed and reduce barriers. In achieving an organisational goal, partnership should be as open and transparent as possible. The RCGP framework highlights that partnership should be built on trust, reciprocated respect, putting the needs of patient and the public first and support from both parties in delivering best possible care. According to this, service users will be more likely to be honest about their eating habit, lack of physical activities and so on as mentioned in the poster. This will enable partners to work with them at an early stage. CRITICAL APPRAISAL 2 Scenario This is a hypothetical case scenario of a reported increase in childhood obesity in a local community (Mumbai) in India which led to serious health problems. A multiagency meeting was formed with the municipal agencies, schools, health care institutions and public health commission to discuss the issue and make policies. A health need assessment was conducted which involves the local GP`s in that area to assess the needs of the local people and their lifestyle. The PHC, GP, and others set priorities to formulate policy as a means of health promotion campaign with the aim of reducing epidemic of obesity, make policy on health beverage toolkit and free cycles. The obese children were targeted in this poster; free sessions were arranged and follow ups with promoting sports. A consortium was formed for the formulation of policy; however there were differences in opinion shared among the members and the leap strategy was used to resolve it. A request to open tender was used in accordance to procurement rules including MAPPS strategies. The policy was implemented using PANTF and CDCP. Results reported and contract monitoring were updated quarterly with the health and well being board with 3monthly follow up meeting with schools to access their progress. The poster stated continuous monitoring and evaluation was done. Strength The poster highlighted principle of the east midland framework and competence 6 of the WCC framework to buttress their reasons. The principle starts that the needs of the users should be put first ensuring that they are engaged and consulted. The competence is also in accordance, it states that the local needs of the population should be prioritised during investments; the service required should be stated. Furthermore, the poster demonstrated a joint partnership in developing a policy, by forming a consortium. However conflicts were resolved amicably using the LEAPS (listen, empathize, ask, paraphrase and summarize) model and an outcome framework was generated. Weakness Commissioning is led by groups of General practitioners, the nurses, local health authorities among many others to promote the health of d people or population. The poster fails to identify who the commissioners were and to give a clear and understandable introduction. There is no evidence to confirm the issue been stated, there was no description on how the health needs were accessed and prioritised. However, according to the National institute for health and care agency (NICE), a 5 step approach to HNA was described. The poster fails to identify the first step of the guideline which states that in starting a commissioning, commissioners should identify health priorities (Cavanagh and Chadwick, 2005). Similarly the WCC framework states that in commissioning a new healthcare service, it is vital to review current provisions as part of the health needs assessment, this involves assessing existing services if available, how they are being used to meet the local needs and also to identify gaps and overlaps (DoH, 2007), however the poster does not indicate any review of previous service while planning to implement a new service which aims to resolve the issue of increased prevalence in childhood obesity in the local community. The poster identified the type of procurement used in obtaining a service according to the procurement rules. However, it did not mention how tenders were invited and who won the bidding. In an open procurement, according to the DoH (2010), all interested candidates are invited to tender through an advertisement with a clearly specified desired service to enable the bidders know what is been procured. According to this, this was not demonstrated; therefore the poster did not exhibit one of the overarching principles of procurement (Transparency). However, abbreviation such as PANTF and CDCP were used but not explanatory. The term of contract was not clearly stated and not understood and the expectation was not clearly stated. The poster did not take account of every activities and quality requirement. Also, in monitoring and evaluating the service rendered, there were no specific highlights to indicate how this was going to be achieved and how the performance was going to be measured. Therefore it can be said that this poster does not correspond with the WCC competence. This competence clearly states that the process of monitoring includes; finding out the view of the users and the local authorities and also having a feedback on the service commissioned. Finally, the poster did not identify the practical aspects of commissioning a health care service which are in 3 stages; the planning, procurement and monitoring. Lessons learnt In critiquing this poster, more knowledge has been gain in conducting a comprehensive literature review that serves as a basis to highlight the strength and the weakness. The poster failed to identify a lot of key strategies in commissioning. The WCC Programme was launched due to the recognition of the need for commissioners to improve in the effectiveness of carrying out commissioning. However, the key lesson gained is without a proper understanding of commissioning principles or without having a strategic plan, it will be difficult to identify the useful frameworks and guidelines which invariably lead to poor commissioning of a service. CONCLUSION Public health professionals play a vital role in commissioning a service for example the General practitioners in the new NHS requires the support of the public health professionals in commissioning. However, this essay has described commissioning in different words but can be summarized as an ongoing process that is applicable to all service rendered to meet the needs of the people no matter who is providing the service. Local Services can be rendered either by the authority, the National Health Service or other independent sectors (DICP, 2011). Commissioning is a cycle of strategic activities concerned with assessing the needs of a population, setting priorities and developing commissioning strategies to meet in accordance to the local and national target, monitoring and evaluating the health outcome (DICP, 2011). Similarly, a good heath care commissioning should be based on a foundation which ensures that evidence based practice is implemented to deliver the best possible care and the people should be empowered and supported to care for themselves and be involved in the commissioning process. The posters were critically appraised using the East midland framework for regional commissioners, World class Commissioning principles and the Royal college of General practitioners. The two posters illustrates a theoretical commissioning condition, the first poster shows the importance of a survey using a focus group and a questionnaire as an important tool used in assessing the needs and ensuring that they are engaged and consulted. It helps to understand what service was needed to be purchased and this abides with the East midland commissioning framework. The 2nd poster was less rigorously demonstrated and shows the importance of the need of effective commissioning skills, knowledge, the framework, core competencies and guidelines needed to implement a successful commissioning service. The two posters had weakness of transparency in common. Transparency is an important overarching principle of procurement that every commissioner`s have to be accountable for by publicly accounting for expenditures, the service commissioned and its quality. For example, in the UK, it is compulsory for commissioners to advertise procurement and contract awards on the NHS website. Also, once the contract has been awarded, it’s important to provide feedback to any unsuccessful bidders and to allow some time before notifying the contract award decision and executing the contract. However, the key lesson in procurement is the contract for a commissioned service should focus strictly on quality and patient outcomes which can be achieved using a key performance indicator which are usually published at the beginning of the procurement process, to enable potential bidders develop a specific target to aim at. REFERENCE Cavanagh, S., and Chadwick, K. (2005) Health Needs Assessment at a glance. Available at: http://www.nice.org.uk/media/150/35/Health_Needs_Assessment_A_Practical_Guide.pdf (Accessed: 25 May 2013). Developing intelligent Commissioning (2011) What is commissioning'.Available at: http://www.yhsccommissioning.org.uk/index.php'pageNo=539 ( Accessed: 28 May 2013). East Midlands Framework for Regional Commissioning (2007) A framework of resources and support. Available at: http://www.regionalcommissioning.co.uk/section/5_commissioning_principles/ (Accessed: 23 May 2013). Great Britain. Department of Health (2007) World class commissioning: competencies. 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