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Thought of the day: Patient Orientated Research

15 Nov

What is patient orientated research? Sounds like a bit of a well-intentioned phrase coined to make researchers feel like they are doing something useful, whilst making patients feel like they’re at the centre of the universe. If you take off the cynic goggles however, patient orientated describes research that is answering a much needed question, that will ultimately help improve patient experience or quality of care. Now this is true public health in action, and as corny as that sounds, I think it’s important to keep the individuals in sight when working in public health.

Commissioning: a rookie’s guide

1 Nov

Commissioning: what does that word mean to you? I had no idea  when I first came across it but it sounded pretty dull. Turns out it’s not dull at all, in fact it’s possibly one of the most interesting aspects of a healthcare system if you’re interested in that kind of thing (as I am), particularly if you are in the UK. As to why that’s relevant, onwards we go…

So what is it?

Commissioning is all about buying the right healthcare services for your population. In addition to purchasing responsibilities, the use of the word “commissioning” as done in the UK indicates that the role also involves extensive strategic planning and setting priorities etc.

It is obviously massively important in any healthcare system but in the UK this concept of commissioning has undergone multiple costume changes in the last two decades, making it a rather “hot” topic.

What’s happened in the UK?

A lot actually. The following is mostly based on the chapter of Commissioning written by Judith Smith and Natasha Curry, at the Kings Fund.

The first most important reform affecting commissioning was Thatcher’s New Public Management reforms in the early 1990s. It was the birth of commissioning if you will, as it was formally split from healthcare provision. It was supposed to overcome the information asymmetry that favoured providers.

Then in the early 2000s, new Labour came in and made PCTs in charge of commissioning. As Smith and Curry have written:

“The PCT model was predicated on a belief that strong local commissioners would be able to assume financial risk for a defined geographic population, providing community health services, and buying other services”.

In essence, this regional level of commissioning meant that the financial risk of making sure that the population’s needs were being met appropriately was divided up between 303 statutory bodies, making it less risky for central government, which was paying all these PCTs out. Having relatively decentralised regional level services meant that there was also the opportunity for individual PCTs to shape their commissioning on grounds of their particular population’s needs.

The Labour government also brought in practice based commissioning, a voluntary scheme whereby a GP practice or a group of practices could ask their PCT to delegate a budget to them. This meant that the GPs themselves could plan and commission a defined set of services for their patients, either from themselves or other providers. The GPs were allowed to keep the financial savings that were made for other services, which acted as an incentive to prevent overspending. As it was voluntary however, some argue that it led to a “two tier service” for patients, depending on whether their GP practice had chosen to get involved in  commissioning or not. There is also limited evidence that PCTs and PBC has improved health inequalities and efficient use of resources. Also, no-one in the public knew about commissioning; this low profile and lack of legitimacy meant that there was weak downwards accountabiltiy and little PPI, an important aspect in all strands of healthcare.

Now fast forward to 2013: the Conservative government are again in power, and both PCTs and practice based commissioning has been abolished. So what remains? New bodies called clinical commissioning groups (CCGs) have been set up to take over the responsibility of around 60% of all commissioning done in the NHS. The NHS Commissioning Board (NHS CB) remains responsible for commissioning specialised services. It is hoped that as CCGs have lots of clinical representation (nurses, clinical directors, doctors, GPs), they will know best to align financial risks and incentives and keep a control on service provision.

The problems

There are several major challenges that face CCGs once they get their acts together. Alongside coping with system-wide changes to public health, the HPA, social care etc., they must focus on maintaining and improving population health in the face of budget freezes and further economic challenges. That’s the most obvious issue I guess.

Secondly, as GPs now have a major role in where resources go, there could be a shift in patient doctor relationships. GPs who sit on CCGs may not have the time and/or skills for effective commissioning. Also, for example if you’re a GP whose CCG has just made a decision on shaving off the budget for COPD clinics or something, talking to all your COPD patients could get a little awkward knowing that you’ve contributed to that decision. In all honesty I’m not sure to what extent this could be a problem as I would have thought that the majority of patients wouldn’t know what their GP did outside of their office.

Thirdly, the key word of the Coalition government’s approach to Healthcare (and everything else) has been “COMPETITION”. Simultaneously however, there is an increasing movement towards integration of services, which has a strong and growing evidence base. How these two ideas (which seem at odds to one another) will be balanced is something I’m sure a lot of CCGs are still worried about 7 months down the line.


It’s not all bad news however, and CCGs have great potential to do good. Merging PCTs may make it easier to influence large providers. They also offer a new face of commissioning which could be more accessible to the general public. With patient and public involvement (PPI) being so important, this has great potential. Also the shift in focus from process led frameworks to an outcomes framework may be beneficial.

Patient and Public Involvement (PPI)

17 Apr

Previously I had always overlooked PPI in favour of other more exciting things in healthcare, like the social determinants of disease and the importance of defining quality and measuring quality. Nevertheless, I can now see why patient public involvement is increasing in popularity and prominence in the world of public health and beyond.

There are the obvious things that you’d expect PPI to improve like patient empowerment and satisfaction, accountability of healthcare providers and appropriate treatment and care. In addition, PPI has been shown to improve quality of care which in turn can lead to increased compliance and better health outcomes. Nevertheless, with the above attributes, PPI remains a tool to improve the patient’s outlook on life with apparently very little benefit for the health professional or indeed, the health system itself.

Currently however, extensive patient public involvement is becoming a widely realised necessity to the health systems of the future. Okay that sounds grand but hear me out: we are seeing a massive epidemiological transition in the burden of disease globally, with increasing prominence in long term diseases such as diabetes, cardiovascular disease and mental health problems. Alongside this, ever-tightening budget restraints and a history of unsustainable spending is forcing many health systems along with the NHS to reconsider its action plan. We all know primary health care is the crux of a cost effective healthcare system but with PPI, it can be improved and enhanced even further.

Increasing PPI offers the opportunity to shift the focus from a reactive healthcare system dependent on specialised care in hospitals to a proactive healthcare system represented by extensive localised networks of community services. In doing so, PPI can help shape a much needed reform to fit the needs of the population. PPI can allow systems to be adapted to a population’s cultural or otherwise non-medical needs.

The Health Foundation’s scoping paper written by Angela Coulter (2009) gives many local examples in the UK that show the impact of various PPI projects. Of what I read (exam time dictates selective reading), it was really useful seeing how PPI was improving not only the patient experience but was also increasing efficiency of the health system.

The growth of ideas such as the Third Way and co-production is perhaps a reflection of the populist appeal they hold. PPI is a great way in which we can humanise the often bureaucratic and heartless health system, transforming its image for the public. Additionally, PPI holds great potential in accelerating the drive for efficiency within the healthcare sector without the need for introducing market principles or competition directly. PPI is a necessary companion to primary health care and it holds promise of salvaging the UK’s healthcare sector from its predicted trajectory.

The NHS and patient safety

5 Feb

Sir Liam Donaldson told us last week in a lecture on patient safety that 1 in 300 patients admitted to a NHS hospital die a preventable death every year. For such a rich and developed country, 1 in 300 is unnecessarily high and reflects pretty poorly on the current NHS. Although this great British institution is a great achievement, it also screams of inefficiency and unsustainable practice that threaten to shorten its days as we know it. The warning bells for the NHS have been ringing for quite some time, and a systems wide change is desperately needed. Will the reforms (due in April) improve the NHS? I don’t think it should be discounted, despite the vast opposition to it, but the stress of implementing such a fundamental change to a complex health system short on funds is unlikely to show immediate results. Nevertheless, I’m inclined to remain hopeful (should that be naive?): opposing change is no use when it’s already happening around you.