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Cooperative Commissioning Dec 10

Cooperative Commissioning Dec 10

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Published by Brian Fisher
A new way of planning local health services that supports coooperation and integration.
A new way of planning local health services that supports coooperation and integration.

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Published by: Brian Fisher on May 30, 2012
Copyright:Attribution Non-commercial


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 A tariff system can create a confrontational relationship between sectors -particularly between primary and secondary care. This can createinefficiencies and the risk of fragmentation. Too often, the patient is at thecentre of a tug of war between primary and secondary care instead of at thecentre of planning his or her care.“The current Payment by Results (PBR) system based on a nationally settariff ensures that patient activity in hospital based care remains the dominantmechanism for financial reward in NHS secondary care….. Rather thanproviding incentives for Acute and Foundation Trusts to collaborate with PCTs….. PBR mechanisms discourage co-operation and can even result ininappropriate competition (or at least adversarialism) across the health caresystem. “The NHS Confederation, in its discussion paper in June 2009 “Commissioningin a cold climate” suggested that “A system based on payment for discreteunits of activity will never create the right incentives for providers to help makecare pathways (or the sum of multiple pathways) more efficient and lesscostly.” They also recommended that the system be redesigned to “encourageefficiency along whole care pathways rather than cost-shifting andencouraging supplier-induced demand.”We need to rearrange incentives to ensure that they encourage NHSorganisations to cooperate and that they reward both quality and efficiency.This can be achieved through Programme Budgeting
Programme Budgeting (PB)
 PB is a retrospective appraisal of resource allocation broken down into“programmes” with a view to influencing and tracking future expenditure inthose programmes.Instead of seeing investment on the level of a hospital or drug budget, thefocus switches to specific health objectives such as reducing the incidence of type II diabetes, reducing death rates from heart disease, improving indicatorsof child health, reducing the burden on family carers of patients with seniledementia, and so on. The ultimate aim is to maximise health gain bydeploying the available resources to best effect.PB helps answer three basic questions:-where has all the money gone?-what do we get for our money?-is there a better way to deliver?
Collaborative Commissioning
Joint (not pooled) budgets are allocated virtually across primary andsecondary care.
These would be along care pathways, based on a programme budgetapproach. The task of the consrtium and local people and hospitals thenbecomes to manage that joint budget so that it maximises efficiencies andpatient care. The incentive for everyone is that savings can be reinvested inthe pathway, or elsewhere, as agreed. In particular, the hospital will gain byshifts to the community particularly if it is in charge of community services,.Pooling budgets has huge opportunity and transaction costs and may notdeliver results. Joint budgets are more likely to enable agreement andfunctional outcomes without the complexities of more formal merger. A calculation of a joint budget in, say, diabetes, would need to include:
hospital costs
Community costs linked to diabetes (estimated)
?social care and health costs (estimated)
Primary care costs linked to diabetes (estimated)
Downstream costs – for instance amputations, costs of retinopathy.This may already have been part of the calculation of the programmebudget
What pathway commissioning could look like
It would be important that clinicians and patients worked together to come upwith the best solutions. The consortium’s role therefore would be:
To set the parameters and outcomes and quality. For instance, wewould expect a reduction in attendances at A+E, a reduction inadmissions from A+E, an increase in patients reporting they hadreceived good quality information and were treated with dignity. Howthis is achieved would be up to the diabetic panel.
Not to pay for poor outcomes – these would be specified in advance egamputations, retinopathy.
To insist on appropriate data – Patient Level Information and CostingSystems
To ensure patient and public involvement
To include pharmacy
To describe the funding envelope
To reduce the funding envelope by 2% in the first year and again by2% in the next.
To project manage the process
There may need to be risk management, both financial and practical
For instance, in diabetes
:The spend would be seen as belonging to both consortium and hospital andmaybe Social Care. If savings were made through more efficient care

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