A surgical approach to value-based commissioning

The wide-ranging government reforms of the NHS have been introduced on the basis that commissioning of local healthcare services is clinically led. However, local commissioning decisions − particularly those relating to treatment thresholds and other criteria − have the potential not only to increase unexplained variation but also to create tension and even disagreements between commissioners and secondary care clinicians.

Clinical engagement and leadership has to be widespread and systematic: “Strong and supported clinical leadership will be critical to engage all parties within the commissioning cycle, if it is to succeed in increasing value, improving quality and delivering a safe and effective NHS.” (Phillip DaSilva, 2012)

‘Surgeons used a language based on effectiveness and quality, commissioners a language based on value from a population perspective’

In this context, “value” relates to the relationship between the healthcare resources put in and the extent of the health benefits realised. Maximising value is the primary objective of the Department of Health’s quality, innovation, productivity and prevention Right Care programme: the value that the patient derives from their own care and treatment, and the value the whole population derives from the investment in their healthcare.

An ambitious and pioneering project under Right Care, in partnership with the Royal College of Surgeons and the Surgical Specialty Associations, is establishing clear, consistent and credible value-based commissioning guidelines for a wide range of surgical procedures. This is in order to produce better value clinical practice using strong engagement with surgeons, commissioners, other healthcare professionals and patients.

Decision-making processes around the commissioning criteria and thresholds for surgical procedures have long been the subject of debate. This has regularly involved public concern from clinicians, manifested in negative media coverage about risk to patients, “cost cutting” and “rationing”.

Underpinning this coverage has been concern from professional bodies that commissioning approaches based on lists of procedures deemed to be of “limited effectiveness”, “low value” or requiring a “threshold” result in inequitable patterns of service delivery − leading to press assertions that a “postcode lottery” has been disadvantaging some patients.

Variations in surgical procedures

Work undertaken by the Public Health Commissioning Network in 2009-10 revealed significant policy differences between primary care trusts for many different clinical activities. Surgical procedures in particular had wide unexplained variation.

It was observed that there was an inconsistent approach to commissioning of surgical procedures. That existing surgical procedures were sometimes classified as being of low clinical value with constraints being put on them. And surgeons and commissioners used a different language when they met. The former a language based on effectiveness and quality, the latter a language based on value from a population perspective.

‘The commissioning guidance is not intended to replace existing clinical guidelines or evidence-based research, but to add to them’

Population ageing will be the factor imposing pressure on surgical specialties, notably orthopaedics, urology and ophthalmology, because of increasing need. In response, the medical director of the NHS, Sir Bruce Keogh, commissioned a project by Right Care and the East Midlands and London strategic health authorities to engage professional bodies in developing value-based clinical commissioning guidance for elective surgical care pathways.

At the same time, it was recognised that it would not be correct to set inflexible national thresholds which could potentially compromise the ability of clinicians to make decisions based on the particular needs of individual patients.

The project, sponsored by NHS England, has three key objectives: to reduce unexplained variation in rates of elective surgical interventions; to reduce locality based “postcode lottery” variation in the provision of surgical services; and to provide ethical, sustainable and consistent evidence-based advice on the commissioning of elective surgical services.

A fundamental principle of the project has been that of partnership − in particular, with the RCS, the 10 surgical specialty associations and the National Institute for Health and Clinical Excellence. This has ensured strong clinical engagement and ownership.

Consistency of approach

A manual was developed, setting out the processes and criteria to achieve a consistency of approach in designing clinical commissioning guidance. In signing up to these, the associations and the RCS committed to producing guidance which:

• supports clinical commissioning groups to commission high-value care for patients with conditions amenable to surgical intervention, through the description of evidence-based, high-value care pathways;
• highlights variation in the provision of surgical services;
• describes process and outcome measures that allow commissioners to make informed commissioning decisions;
• provides levers for change within the local healthcare community;
• links to patient and clinician-facing information, and practical examples of high-value care pathways that have been implemented in other healthcare communities; and
• identifies gaps in knowledge and priority areas for research.

The RCS was resourced through Right Care to project manage and coordinate a tight schedule in 2012-13, facilitating and supporting specialty specific guidance development groups established under the auspices of respective surgical associations to do the detailed work.

Each group has had broad representation from those involved in commissioning, delivering, supporting and receiving surgical care. They have included CCG commissioners, primary and secondary care clinicians, as well as at least two patient representatives − with the emphasis on a whole pathway approach, in which the surgical procedure under consideration was only one element of an individual’s care. In addition, the sponsoring surgical specialty associations has been able to consult internally and to involve its fellows, members and registered stakeholders in the scoping exercise.

The groups have worked on producing guidance, initially for 28 common types of surgical intervention, with more topics under development. The selection of areas for this first phase of commissioning guidance has been influenced by a range of criteria, including:

• The burden of disease: population, morbidity and mortality.
• Clinical priority: is there an effective treatment that may reduce morbidity or mortality if widely adopted?
• Clinical uncertainty: is there wide variation in practice or outcomes?
• Resource: what is the resource impact on the NHS?
• Strategic importance: is it a priority for NHS England?

The commissioning guidance developed is not intended to replace existing clinical guidelines or evidence-based research, but rather add to them by providing information to support commissioning. This may include data on current service provision, patient outcomes in the relevant population and levers for change such as audit and peer review measures and quality specifications.

A requirement has been that each piece of commissioning guidance must undergo wide public consultation and be peer reviewed by at least three independent referees who have had no prior involvement.

Formally accredited

As a result of the robust processes and comprehensive clinical engagement, the guidance development process was formally accredited by NICE in March and guidelines will be highlighted on NHS Evidence and published on the websites of the RCS and surgical specialty associations from June.

Two new web-based tools have been developed by the Midlands and East Quality Observatory to provide data to inform commissioning guidance − the Procedures Explorer and bespoke “quality dashboards”.

The Procedures Explorer is designed to deliver information on local clinical variation for the care pathways covered by the commissioning guidance. Drawing on hospital episodes statistics from the Health and Social Care Information Centre and validated by professional coding auditors, it shows data on secondary care surgical activity − organised into individual specialties and then clinically relevant conditions, such as “sore throat/recurrent tonsillitis” or “knee pain”.

‘Instead of commissioners imposing thresholds, clinicians have the opportunity and knowledge directly to influence commissioning decisions’

Two “lenses” are applied to the data, to give both a commissioner and a provider perspective. The former allows variation in the standardised rates of surgery to be visualised for resident populations (the commissioner’s view) at local area team, CCG and GP practice levels. The provider view shows the same data, but with the capacity to drill down to specific specialties, conditions and potentially individual surgical teams.

Stimulate questions

As a public-facing online tool, the Procedures Explorer is equally accessible by patients, the public, commissioners and providers. The information provided initially covers a year of data on activity levels, length of stay, readmission rates, day case rates, reoperation rates and mortality rates. It is an interactive resource which allows users to select conditions, perspective and the level of view − as well as different graphical styles.

The tool is available on the Right Care website, supporting the NHS’s mission for information, transparency and patient choice. Quality dashboards for each surgical specialty are being developed to sit alongside it, presenting key measures of quality such as mortality and readmission rates at the level of each CCG. These are due to be launched in the summer.  

Both tools are designed to stimulate questions about healthcare at a local level, giving service commissioners and providers the wherewithal to challenge unexplained variation. In particular, they will enable surgeons and other frontline clinicians to take a population view, where they can see how their decision making in individual cases has implications not only for the patient in front of them, but also, because of the finite resource they are working with, for the many potential patients not in the room.

The development of this guidance offers a new coherent and authoritative approach to NHS commissioning. Its launch is being phased, with the first stage involving a comparatively small set of conditions and relatively high-level data. As the process matures, it can be extended to more complex procedures and richer data. The programme will be explored with other professional organisations where there is variation in commissioning; for example, the Royal College of Ophthalmologists is looking to gain accreditation and produce guidance on cataract surgery.

The approach of this project enables the NHS to be more confident in making decisions about changes to healthcare services − knowing they will be based on robust evidence and strong clinical ownership. Instead of commissioners imposing thresholds, clinicians have the opportunity and knowledge directly to influence commissioning decisions.

Nigel Beasley is ENT surgeon at Nottingham University Hospitals and clinical lead at Right Care; Jo Cripps is head of professional affairs at Royal College of Surgeons; and Simon Swift is director at Midlands and East Quality Observatory