How to improve commissioning for long term conditions

National Voices has identified three sets of people who can add value to commissioning for people with long term conditions.

The first set is the people who have long term conditions. The people who manage these conditions are the people who live with them – not the health and social care services.

The first step in adding value to commissioning is therefore to recognise that improved outcomes stem from better management by the people concerned. There is strong evidence for this and it means that a large part of commissioners’ role is to put in place the supportive services and systems that underpin it.

The government acknowledged the force of this argument by twice amending the duty of commissioners to “promote the involvement of each patient” in the Health and Social Care Bill.

The resulting Health and Social Care Act 2012 states that both the NHS Commissioning Board and clinical commissioning groups must, “in the exercise of their functions” – that is, in everything they do – “promote the involvement of patients, and their carers and representatives, in decisions which relate to… prevention [or] their care or treatment”.

The board will publish guidance on how to do this. In the view of National Voices and the Health Foundation, which campaigned for the amendments, individual patient involvement must encompass:

• building the health literacy of people with long term conditions – that is, helping them learn to use information about their condition, treatment options, and ways to manage it;
• stimulating a new culture of care in which people are “activated” – supported to set and achieve their own goals and to participate in decisions – rather than treated as collections of symptoms, and
• participative care planning, so that people know what packages of care they have, how to use them, and what to do if things change.

So the first set of people who can add value are the people with LTCs themselves. They can become active in managing their care and achieving objectives – and commissioners can multiply that value by generating a supportive care culture.

The second set of people who can add value are those professionals who are in the best position to coordinate care. What people want is better care coordination – which may or may not involve the actual integration of services. The default provider of this should be the GP, but it can be delegated to other professionals such as nurse practitioners, specialist nurses, a consultant team or a social work lead.

Commissioners who are contemplating programmes of integrated care should therefore consider the roles of all members of the actual or virtual team with whom patients will have contact, and bring them into the design of services. The care coordination role needs to be explicit and performance managed. Integrated care that does not provide this tailored care coordination will have failed.

The third set of people who can add value to commissioning is the wider circle of people who know what it is like to live with a long term condition, including people with long term conditions; peer groups, such as local peer support groups; community groups; and patient organisations such as National Voices’ members. They should be brought into the whole process of identifying needs, agreeing strategies, redesigning and recommissioning services, and monitoring their effectiveness.

Co-design with these groups can happen at the joint strategic needs assessment and health and wellbeing strategy level, and at the commissioning level.

Voluntary organisations can have a particularly strong role here as they can help to identify the population in need and bring them together for consultation and input; marshal qualitative evidence of what people with their condition need; and provide specialist knowledge.

Commissioners need to be able to understand, accept and act upon a recognition that these third sector organisations do not want to be seen in the light of potential providers in this context but as agents to promote and secure the best quality of support and care.

To make best use of our highlighted categories of value-givers – individual patients managing their condition, the professionals who can best coordinate care, and collective groups who can co-design strategies and services – there will need to be a reorientation of the commissioning mindset. National Voices’ Principles for Integrated Care, endorsed by NHS chief executive Sir David Nicholson and the King’s Fund, are offered a good place to start.

Don Redding will be speaking at the Commissioning Show on 28 June.

Find out more

Principles for integrated care