The practice of commissioning healthcare from a private provider: learning from an in-depth case study

Understanding and use of the term ‘commissioning’

Not surprisingly, given the full title of the Livewell programme which includes the term ‘service redesign’, respondents did not particularly like the term ‘commissioning’:

‘.....We wouldn’t use the word commissioning at all. And, actually, we think it’s over-laboured in the UK. Far too much time and attention is given to commissioning and far too little time and attention is given to services.... we really want to see a sea change. We want to demonstrate what services look like when they’re good.’ [BM].

The term ‘service redesign’ was preferred by all respondents, apart from the PCT chief executive. This redesign project was developed, designed, and signed off by patients, carers, care givers, and other stakeholders. One respondent asserted that the term commissioning contains an inherent assumption that there is certainty about what is required, although in reality there may not be certainty or good evidence about what will work.

The second point made was about the use of integrated care as an organising principle. This was illustrated by thinking on services improvement in the programme around a fictional woman called ‘Maisie’ who is a carer for her mother who has dementia and who has her own health problems. Third, there was support for the notion that effective commissioning delivers better quality for a lower cost. Fourth, there was emphasis on effective ‘hands on’ micro-commissioning (the doing of service redesign) at the frontline, including the use of analytics, financial modelling, and making use of the experiences of users and care-givers. Finally there was a warning about the need not to underestimate the length of time required to achieve change and the emotional labour of the commissioning work:

‘....It [commissioning] will make a difference provided everybody has got a lot of time, the clinician sitting there has got a lot of time to do all the job. Even if you understand what needs to be done, to change the system it takes a very, very long time. Sometimes the secondary care they work in their own way, they may not agree with you and sometimes even if they agree with you, to change them it takes many years and sometimes (dividing the pot) that causes a lot of problems....’. [GP3]

Challenges and choices in primary care

Respondents described significant problems in motivating patients to choose healthier life styles and to look after themselves better in such a deprived area, where the patients have so many other economic and social problems to contend with. They also reported pressure by patients for referral to specialists in a search for medical solutions, and other struggles to contain care outside hospital. The reality of the practice of primary care was exemplified by the comment below from a GP from one practice:

‘......Why do we send to hospital? I’m not talking about somebody with a really complicated history, I’m talking demented lady, living at home, had a fall at home, when you go [to their] home, no relatives, nobody to give them medicine. They didn’t take their medicine for two days so you ring the local social worker – no answer - and if you look for a nurse, there’s hardly any community service now. So at that time only one person will answer your telephone call, that is the hospital. Nobody else, that is the only hope for you, that the person goes to hospital and then at least they’ll be better for that and somebody will feed them, somebody will give them medicine and do some basic tests. But if we [had] certain things available.... we wouldn’t need the hospital’ [GP3]

In this context, respondents reported six main ambitions for the project: to seek beneficial changes to people’s health, help patients to take greater control, change how services are used, secure greater self-management and management in primary care, deliver strategic thinking on whole system redesign, and to make savings. The chief executive from the PCT put it like this:

‘What we wanted to see was the evidence, captured elsewhere, of how changing the way that care is delivered can result in some really beneficial changes to patients’ health, on the one hand, but also change the way that patients used healthcare facilities. So, we were working with [name of private sector provider] to look at the changes to health for people with long term conditions when they were given support in a different way.... And in particular, we were looking at morbidity, [reductions in the] number of hospital admissions that might result from people being able to self-manage themselves in a more effective way. But also being able to receive that support primarily from primary care rather than actually to have to go into hospital..... [and] I guess we saw the project and investment we put in has potential to lead into longer term savings because, of course, with PBR we’re paying for every time that people with long term conditions enter into a hospital environment, and we knew, of course, all the evidence shows us is that people with long term conditions are those that occupy the majority of hospital beds....’ [PCT CE]

There was not absolute consensus. One GP [GP2] was doubtful that the telephone care management service would diminish A & E attendances although it might reduce hospital admissions. Another GP [GP3] thought it would help with improving patient understanding of their long term condition, modify lifestyle behaviours affecting their health as well as halting the ‘disease process’, reducing hospital admissions, and lengths of stay. Related ambitions were to change perceptions in the minds of patients about long term conditions having a wholly external locus of control, to challenge folklore about the need for A & E attendance to provide confirmation of the severity of the health problem, and to tackle some of the mental health issues that often go along with having more than one long term condition. A powerful image was conjured by one respondent in describing the importance of giving ‘armbands’ to the ‘weak swimmers’ - which is what the telephone support service has done.

Although the foreseen effect was to reduce use of secondary care services, the point was made that the primary aim of the project was to improve care for patients.

Roles and relationships

Four aspects to roles and relationships came through strongly in the interviews. First, the primacy of the practices, and in particular the GPs, in driving the service redesign project; second, the close relationship with the private sector provider; third, the spirit of co-design and co-production with the private provider; and, fourth, the history of a positive relationship developed with the Primary Care Trust (PCT) the local body responsible for healthcare commissioning at the time of the study.

One of the reported characteristics of this project was that the level of commissioning was spearheaded at the practice level rather than at the PCT. This meant ownership was at that level rather than the PCT ‘selling’ the initiative. Our participants indicated that the project was led, in the main, by the doctors rather than by nurses or other staff from the practices. It was doctors who decided who should be excluded from invitations to participate in the service (for example because a patient had a terminal illness). Nurse practitioners and practice nurses attended briefing sessions and were involved in the development of the group consultation service. Of the primary health care team, community nurses from the local NHS community service organisation run by the primary care trust probably had least exposure to the project. There was also no evidence that the local hospital were involved in the design. Practice managers were involved in liaising with the private sector partner particularly around access to patient records. There was at least one example of ideas from the practice staff however that had not appeared to have percolated up either to the practice or further. Patient group members were invited to quarterly forums and gave views on the text of letters to be sent to patients and on survey questionnaires.

One example of collaboration was the very close co-design of the telephonic care management service with the private sector partner. After the risk stratification tool had been utilised, GPs in all 5 practices checked their lists of patients for suitability for invitation to telephone support service. As the private provider lead said:

‘To us it’s just patients on a list. We don’t know who’s hard of hearing, who has compliance issues, who is even possibly in day care during the day, so we do rely on them really being able to go through that list at a high level and just being able to say: look this person’s really not appropriate. And sometimes our risk model will miss patients that really could benefit, so if they do come across somebody that they think would be perfect for the programme we can invite them into the programme and get their data. So I think their [GP] involvement there has been really instrumental in that initial patient determination’ [PPL].

The private sector partner had been initially brought in at the first phase of the Livewell initiative in a strategic partnership, without a formal tender: ‘an agreement in principle that we wanted to work together’ [BM].

They were engaged for their expertise and fresh outlook to offer overall programme management support, provide the in-depth practice profiles on activity and costs, be the clinical lead on the telephonic care management service, and to be partners in strategic thinking on whole system redesign (the ‘think-tank’ work). The private sector partner was described by respondents as prepared, organised, interested, patient and responsive:

‘The [Private sector partner] were the only ones who wanted to work with little people like us and develop a product’ [GP4].

The overall relationship was described as close, with a strong rapport, working as one team, learning together and a desire for a win-win between both parties. Latterly, with the advent of the second phase of the Livewell initiative, which was a single action tender and recognising that both parties owned some intellectual property, a more transactional tone was reported to be coming to the fore at times with more of a focus on KPIs (key performance indicators). The second generation practices reported a courteous but more distant relationship with the commissioning support firm, indicating in their interviews that the first phase of the project had done much of the trialling and they had been able to take advantage of that.

On the whole, the spirit of co-design, co-production and learning together came through very strongly. A trial and error approach was adopted as it was agreed that a US model without adaptations to suit the multicultural local population in this inner city area in England would not work. For example, not only was the initial determination of the choice of patients to receive the telephone support service co-delivered in collaboration with the practices, but the system for feedback and referral back to practices of patients by the telephone care management nurses was also redesigned, following some difficulties with conveying uncorroborated patient viewpoints about perceived deficiencies in GP surgery services. One respondent, in relation to his/her role as a GP commissioner, commented favourably on being able to work with a healthcare provider ‘from the inside’ and a preparedness on the part of the private sector provider ‘to work with the little people’ in contrast with the more distant relationships experienced with providers in normal circumstances.

There was a history over some years of the general medical practices developing positive relationships with the PCT. More than one respondent described humorously how the PCT had been ‘drip tortured’ into investing in the initiative. Unusually, the PCT (by the admission of the PCT chief executive as well as other respondents) encouraged and supported, rather than commissioned this project. But the investment was not easily won and required tenacity:

‘It’s....about creating some of those relationships and the relationship building...... Sometimes I don’t agree with what people say and you don’t agree with their mode of working, you just have to stick with it. It requires staying power. And also for them to know that you are, we are the organisational memory here, I’ve been round so many times’ [GP4]

Impact, adoption and spread of innovation

In terms of evidence, respondents indicated that, for the time being, the positive impact in the Livewell programme was largely experienced by very positive patient feedback from the telephonic care management service rather than from statistical evidence about a decrease in A & E attendances and admissions. There are plans in place to report to practices changes to biometrics of affected patients, such as blood pressure, levels of blood sugar, weight, breathlessness and so on, recognising that changes are likely to take at least a year before they are seen.

Second phase practices acknowledged that much of the hard work had been done in the first phase and that although they had not been involved from the beginning, they benefitted from that. They gave the impression of being more casual in their motives for joining the project. One also reported that having been invited to join the second phase, they decided ‘why not...give it a try’? [GP2].

Respondents reported issues with followership, embedding innovation such as risk stratification in general practice and the challenge of scaling up. The second phase practices were more likely to have either the clinicians or the practice manager closely involved in the project rather than both. There were some problems expressed with practices signing up but not necessarily wholly committed. One practice indicated that they felt ‘a little in the dark....and not near the [lead practice] level [PM 1]. Not all were convinced of the value of group consultations. In parallel with this, those considered to be the innovators or entrepreneurs also reported experiencing a degree of mistrust at times from their wider peer group.

On the other hand, the involvement of a wider group of practices had tested the project conception and design, and resulted for example in the programme embracing the challenge of managing the psychological aspects of long term physical health conditions. One of the practices reported the wider use within the PCT of the idea of the telephone care management service to ring their very elderly patients during the winter period to check that they were ok. Another example was the potential use of the practice profiles developed by the private sector partner to probe cost and value of obstetrics services (particularly for pre term monitoring admissions) and the possibility of primary care based fracture reviews.

Destabilisation: the impact of changes in commissioning arrangements

The influences of health reform were felt in three respects. First, there was an acknowledgement of the changing health policy and political context and not least a change of government and the consequences of this for the private sector partner, as the market for private providers had shifted. Second, it was noted that the project was an invest-to-save project that crossed between the old and new NHS commissioning regimes. This meant that there was some rupture in long term relationships, the new commissioning architecture was complex, Third, PCT staff were leaving so that data extraction process had been delayed by up to nine months, and there was now an absence of the proactive involvement, support and encouragement from the original funder.

Practical lessons for commissioners in the English NHS and other countries

We think that there are a number of practical lessons for commissioners in the NHS in England and for healthcare design, commissioning and procurement in other countries, which relate to our original research questions around media of power and alternative approaches to governance:

1. There has to be an acknowledgement that the very term ‘commissioning’ is problematic and can be a ‘turn off’, particularly for the clinicians who may be at the heart of the process, either as commissioners or as deliverers of care. It is a peculiarly English term. Alternative more acceptable terminology could be considered and may include: service redesign, development, improvement, procurement, purchasing; with clinical commissioning groups becoming the ‘design house’.

2. The case study has shown the benefits of a mode of commissioning characterised by closeness (‘deep commissioning’ or ‘micro commissioning’) between commissioners and providers in service development, recognising the often tortuous path to securing actual improvements for patients. This closeness to commissioners is something that providers too may wish to consider. We do not see this as being necessarily a characteristic of working with a private provider of health care or with commissioning support services. It may however be that in this case the private provider was more innately customer focussed than public sector providers might be. There are also to suspect that the closeness is connected with the nature of complex long-term care and common, undifferentiated complex conditions, for example multi-morbidity in frail elderly often with social marginalisation reasons (see the papers by Porter et al [36], and Sheaff et al [6] in this special issue). We do not yet know what measurable benefits have been achieved by this programme for patients but the high levels of trust and the degree of embeddedness of provider with commissioner stands out and points to a very productive mode of commissioning. More research in this area to understand the circumstances when this approach would be particularly beneficial is called for.

3. The research study is predicated on the existence of a media of power commissioning repertoire, which makes use, alternately, of relational approaches, contracting levers, markets and competition, ideological disciplines, financial incentives and robust management of procurement. The project under investigation favoured the first, particularly in the start-up phase, enhancing a creative spirit of joint enterprise. Commissioners may wish to consider selecting more deliberately which approach suits particular circumstances.

4. We would suggest that the underpinning governance principles for a commissioning repertoire could be amplified to include agency, stewardship, resource dependency and stakeholder frames. In practice, this means that commissioners may select, and switch between, a low trust and high challenge approach with providers (for example when there are concerns about service weakness or failure), a high trust and high challenge approach for generating innovative ideas for service improvement, or an externally focussed boundary spanning approach (building relationships with key stakeholders in the system) for example to enhance reputation, win resources and inward investment.

5. Identification, support and backing for the relatively rare radical thinkers and innovators in the NHS in England, particularly in primary care, would be helpful to speed up the pace of change. In parallel, these radical innovators may wish to consider the value of relationship building and the use of carefully constructed selective long term restatement of their ideas with key stakeholders, described as ‘drip torture’ in this study, as a mechanism for getting their views heard.

6.The consequences of structural reform on the commissioning side of the NHS in England may be a temporary slowing down of innovation and implementation of service improvement due to ruptures in long term relationships in circumstances where these, given the emphasis on negotiated order and stewardship governance, have begun to be productive. There are warnings here for other countries considering embarking on structural healthcare reform. The argument that there is currently a misplaced focus on structural rather than service reform in the NHS to solve efficiency and effectiveness problems has been made elsewhere [39]. This case study offers further evidence of this and spells out the consequences, particularly in relation to the rate of being able to improve services for vulnerable patients.