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For a long time, geriatricians have been trying to influence how services are delivered locally. As complex as the commissioning cycle might appear – with a mix that includes benchmarking guidance, eligibility criteria, streamlined pathways, key performance and quality indicators, financial profiling and continual review – it is essentially about ensuring that the right patient gets the right treatment from the right clinician, in the right place at the right time and for the right price.

To get involved successfully, one needs to understand the pressures and priorities of commissioners, and where the local weaknesses are. Clinicians have solutions to quality and efficiency that commissioners may not realise.

In November 2009, the BGS staged a one day workshop to familiarise participants with various mechanisms for commissioning health services for older people and to examine how they are being used against the changing backdrop of delivery routes, resources and venues.

With increasing demands for quality and efficiency, what the workshop showed was that there is considerable knowledge and forward thinking within the BGS membership that commissioners and managers would like to hear about, particularly as they seek to match the competencies of World Class Commissioning.

Partnerships
In a series of breakout sessions, delegates were given snapshots from different perspectives on successful commissioning, but a common thread running through all the sessions was the notion of “partnerships”.

Speaking of the partnership between geriatricians and PCTs, Eileen Burns reported that in Leeds, geriatricians had been assisting with the commissioning process since 2000 - beginning with a secondment examining the potential benefits of a secondary care geriatrician working with newly developed intermediate care services in the community.

Since then, geriatricians have been involved in many developments including a falls service, rapid response, community matrons, joint care management and an integrated continence service. Inroads are also being made into links with specialist nurses. Work continues to get dedicated proactive input into care homes, a falls service redesign to broaden its scope and, despite some early anxieties, better governance with regular community audit meetings, morbidity and mortality reviews etc. While the approach continues to have its frustrations, the benefits are considerable.

“There has historically been an adversarial climate around money issues,” said Eileen, “but as we are employed half by each side we have managed to not be seen as having an axe to grind one way or the other. We are seen as being even handed by the PCT, as advocates for older people. While there is plenty of information coming our way from the acute side, getting hold of data from the PCT has, until recently, been a struggle. We actually brought some data to them to show how change could demonstrate benefits.”

NHS Quality Frameworks
Drawing on another common theme, Jonathan Potter said that while there was divergence in policy from country to country across the UK, a framework with three universal sets could be identified, namely:

• Advice - National Operating Framework, NICE guidelines and quality standards
  t Implementation – Commissioning, Quality Accounts, NHS Institute, Clinical Excellence Awards
• Assessment – Care Quality Commission, National Clinical Audit, Quality Observatories, NPSA.

The National Quality Board (NQB) came into being post-Darzi. Its role includes aligning the national system around shared goals for improving quality. Importantly, it also advises Ministers and the DoH on priority areas for improving quality and this tops the agenda.

Over the coming years quality, innovation, productivity and performance will dominate all elements of the framework structure. As well as delivering quality, new developments have got to be cheaper. NICE Quality Standards and registration requirements will push high quality care through all the structures.

How does this affect the clinician? Making a difference to quality works when one has a champion who is prepared to take the lead on service improvement. It works when one uses all the levers that will drive change both nationally and locally. Get to know your managers and commissioners. Gather local metrics that can be monitored frequently to support the case for change and to show that change is happening.

Commissioning by psychology
Paul Knight was in more philosophical (and warlike) mode on how services might best use the commissioning culture. Quoting from several military strategists including Machiavelli and Sun Tzu on The Art of War, Paul said: “If you want to overcome things, you have to overcome a lot of innate convervatism. People are comfortable with what they do. As you plan, consider, what it is you actually want to achieve? Is it new? Can you make it seem new? Does it resonate with current political thinking and targets? Do you have ‘facts’ to back up your assertions? Can you ‘produce’ some?”

“Gather intelligence – don’t look for it in the BMJ. Find it in Health Service Journal because that’s what your managers will be reading. You need to know their language.

Engage the main players. Bring them onside. If you don’t get 100 per cent of what you want don’t get in a huff. Consider what of your plan is reconcilable with the direction they seem to be taking. You may manage 75 per cent and still be able to make things work. Be assertive, not angry. Say you’re angry without behaving angry. Think on your feet. Bluff.

Think again, when it doesn’t quite go to plan. Back to Sun Tzu: ‘Military tactics are like unto water; [...]Water shapes its course according to the nature of the ground over which it flows’.

“The people who tend to be successful in driving through service development are those who can change their plans in accordance with what might be deliverable.”

“It’s hard work. Don’t be rebuffed at your first attempt. How you put your argument across may vary with your audience so have different ways of expressing it”.

A commissioning toolkit for falls and fractures
Giving a very practical example of effective commissioning was Finbarr Martin who said: “It is important to get over to commissioners and managers the things clinicians take for granted”. In respect of falls and factures, since the National Service Framework of 2001 and the NICE guidance CG21 of 2004 and TA87 of 2005 there has been sufficient policy to know what should be happening. We now have the emerging powerful information from the National Hip Fracture Database and with pressure from the BGS, the British Orthopaedic Assocation, Help the Aged and the National Osteoporosis Society, we now have the Dept of Health commissioning toolkit for falls and fractures and have been able to harness the potential of the Payment by Results best practice initiative.

The toolkit is not about new evidence. It has pulled together existing guidance and standards, stakeholder and expert opinion, with the intention of giving more clarity on priorities and making progress through four cascaded objectives. All the objectives relate to guidance or policy and offer opportunities for integration with long term care and social care strategies.

Data - essential to quality and efficiency
Emphasising the importance of supporting data, Jugdeep Dhesi gave a further practical example of how South London geriatricians extended the reach of geriatric medicine to improve outcomes for older people having elective surgery. Again, under the heading of forming partnerships, they engaged with a wide range of stakeholders (including surgeons, anaesthetists, nurses, therapists, hospital managers, social workers and intermediate care teams) to set up a new high quality service with the aim of reducing waiting times and mortality and improving patient and staff satisfaction.

Data collection was an essential means of demonstrating the need to redesign the service. The results of their efforts is that a CGA clinic now sees approximately 600 surgery patients a year. The geriatrician led team liaises with the patient, their GP, surgeon and anaesthetist, to see what can be done to optimise the patient prior to operation; what the possible post-op complications might be; and what junior doctors can do to treat these. A letter is then sent to the patient and all professionals involved in their care. There is a twice-weekly geriatrician ward round on all surgical wards to ensure early identification of any post-op complications. A geriatrician leads the MDT meetings on each surgical ward for all staff and all patients (not just those aged over 65) are reviewed.

Blinded by traditional boundaries
Practical advice on engaging in the commissioning process came from Peter Murdoch who advised:

• Make clinical voices part of the planning and decision-making process and use them to get support of public and politicians.
• Agree a shared vision and values – if you have consensus around what you are trying to achieve you can go forwards and do practical things.
• Communication is vital, both within and between key agencies and stakeholders.
• Link your shared desired outcomes to national measures – i.e. reducing A & E attendances
• Older people are the largest group of service users – if you get care right for them you will get it right for almost everyone.
• Analyse what is needed and don’t be blinded by traditional boundaries: what are the prime needs; and where do people need to be? - What are the most appropriate settings?
• You have to break down barriers to have a new whole-system approach and may have to develop new care pathways.
• Focus on the basics – quality, experience, value for money.
• Robust data is all-powerful – it will show you where changes need to occur. The information is in the system but needs to be uncovered. For example, look at hospital admissions by long-term conditions and look at admission rates by local areas.
• Identify where problems are occurring.
• Reporting mechanisms are an incentive for continuous improvement.
• Set realistic goals and plan properly to achieve them.
• Support clinical staff and others in change process
• Ensure consistency of quality and experience – guidelines for all staff help mould a common approach.

“Better can be cheaper”
Speaking under this rather attractive title, Colin Currie illustrated the post-code lottery with a report that a 2006 multi-agency inspection of services for older-people across the three regions of Tayside showed significant divergence in the probability of multiple admissions of over 85s per 1000 of population. While in Angus the figure stood at 50 per 1000, in Dundee it was 71. And in Edinburgh, in the Lothians, the number was higher still, at 83. And great divergence was seen in other key indicators, such as occupied bed-days for multiple admissions of over 75s.

A similar postcode lottery is apparent right across England. The probability of multiple admissions of over 75’s ranges from 2.5 per cent to 9.5 per cent across English PCTs with the number of resulting bed days from less than 1000 to more than 3000 per annum.

For decades, organisational, political, financial, cultural and professional divisions between health and social care have delayed and fragmented care and made collaboration difficult. Neither the acute nor social sectors take ownership of the care of older frailer people. The postcode lottery is intolerable because it costs so much, some of that money is grossly inefficiently spent – and now we have an ageing population and shrinking budgets too.

There are many little ‘projects’ but they don’t seem to get us very far. Instead of limited, single-diagnosis schemes for a multi-pathological population we should be developing effective collaborative care at system level. Most old people live at home and want to stay there. And better care at home for those most at risk of unnecessary acute or care home admission could save a lot of money.

Seamless, accessible and flexible health and social care is rare in England. But it has to be provided, and there are grounds for hope. Despite the complexities of joint commissioning they are doing it in Camden where occupied bed days for over 75s are down 16 per cent. Torbay’s care trust structure, with effective local health and social care teams, has cut bed days by 24 per cent - a good example of cost-effective system-wide care. And in the Isle of Wight, a series of common-sense collaborations and free personal care at home for the most frail, has seen a 35 per cent reduction in acute bed days, and a fall too in the use of care home care.

Integrating health and social care commissioning in Northern Ireland
Speaking on the unique commissioning environment of Northern Ireland, Ken Fullerton said that with increasing dependency come increasing social care costs that may be invisible to health care providers. Health care interventions, on the other hand, may be completely inaccessible to social care providers. For example, according to the National Audit Office, the costs of stroke to the social care budget are 40% higher than healthcare, while informal personal and family care costs are even higher still.

Northern Ireland has for many years had a legally integrated framework for health and social care. Historically, this has not led to practical integration at commissioning or local level as the funding streams have tended to remain distinct, with the larger Trusts being exclusively based around either acute hospitals or community services. Recent major organisational change is increasing integration across the health and social care trusts at the level of delivery, with common budgets for health care, domiciliary care and care homes. However, the balance of commissioning between the single regional board and the local health and social care groups is unclear, while primary care commissioning has not been introduced.

The integrated care team I work with exists entirely within social care and meets every week. Social workers and care coordinators bid for money because their client needs more looking after. These professional staff have not previously had easy access to health systems, while their clients’

increasing levels of dependency have not yet reached the crisis point which would cause a referral to emergency services. My involvement has led to earlier assessment, treatment and rehabilitation which is often enough to avoid, prevent or delay increasing dependency.

Integrated commissioning across the whole system could prevent avoidable dependency and avoid a premature commitment to high cost long-term packages, leading to better individual outcomes and less cost. But there are potential pitfalls. Integrated commissioning brings the risk that health and social care will be fighting for a slice of the same cake; GPs have had little if any involvement in these discussions; and the development of community services may lead to an accelerated decline in assessment and rehabilitation facilities unless this is addressed on a system wide basis.

There are obstacles to be overcome. There’s little evidence base behind integrated health and social care commissioning. Although there are a number of successful local initiatives, not a lot is happening at the whole system level. Health and social care information systems aren’t linked.

To many, integrated commissioning seems a strange system – but that doesn’t mean it’s not worth doing and my experience is that its biggest champions are social workers and their clients.

Abridged from the full report by
R.J Atkins

BGS Newsletter, February 2010
Issue 25 ISSN 1748-634000 25