A few weeks ago we posted a summary at Croakey of the results of a qualitative study that canvassed the perceptions of senior staff, board members, and community advisory group members from six Primary Health Networks (PHNs).
When asked to consider how health care commissioning by PHNs was likely to impact on equity, participants raised concerns about a shortage of funding for some projects, the poor fit of commissioning with Aboriginal Controlled Health Services, a paucity of services to commission in rural areas, and discomfort with the shift from collaboration to competition for providers.
All in all, there was concern that commissioning could entrench, rather than relieve inequitable access to primary healthcare for Australians.
In the the post below, authors from Hunter New England Central Coast PHN take a different view. They say that commissioning is about much more than purchasing services. Rather, it should be seen as an opportunity to optimise resource use across the whole of the health system and, importantly, to tailor services according to community and individual needs.
Jay Rebbeck, Scott White and Catherine Turner write:
The recently published piece Commissioning no cure for Australian health equity, which discussed the pros and cons of commissioning in primary health care, ultimately presented a negative picture for the future of commissioning in Australia, with the introduction stating, “opening primary care to market forces is a poor fit for the Australian context and stands to entrench disadvantage.”
We would argue, however, that this rather bleak prognosis is based on a fundamental misunderstanding of the concept of commissioning. In our experience, when people talk about commissioning they are in fact often describing procurement or competitive tendering. While procurement and competitive tendering can be part of commissioning, they are only one element of it
Commissioning for positive change
Indeed, the challenge of Primary Health Networks (PHNs) explaining how the commissioning cycle operates was a major theme at a recent gathering of 21 Primary Health Networks from across Australia. The Hunter New England Central Coast PHN organised the event so PHNs could come together to discuss and showcase their commissioning experiences.
The Kings Fund describes Health care commissioning as a process of “planning and purchasing health services to meet the health needs of a local population”.
When reading this definition it seems most people focus on the purchasing part and ignore the planning part, as well as missing the fact that commissioning is a process, not a single act.
At our recent PHN commissioning showcase we agreed on the importance of viewing commissioning as a real time change process that strives to move our health system towards more sustainable models of care.
International experience tells us that where commissioning has been most successful, it has been viewed from a change management perspective.
By thinking about commissioning in this way we can bring a whole range of powerful tools into play such as:
- Setting the strategic direction for the whole health system
- Designing services that meet local health needs
- Getting the balance right between competition and collaboration
- Building primary care capability and aligning services with identified needs
- Introducing new payment incentives such as outcomes based payments
- Engaging meaningfully with clinicians and the community
- Supporting the development of key health enablers like digital health
While there seems almost universal agreement that our health system is on an unsustainable trajectory and needs changing there is no unanimity on how it needs to change.
A golden opportunity
Commissioning provides an opportunity for us to implement change. As the organisation charged with implementing this change, our PHN is fully cognisant of the need to work collaboratively with our stakeholders to make commissioning a success.
In the Hunter New England and Central Coast we are operating on the same premise as that advocated by Professor Ian Hickie who wrote in a recent MJA Insight article:
“My own view is that PHN-based mental health reform is the best opportunity we have had in 30 years to deliver real improvements in non-hospital-based and regionally-relevant mental health and suicide prevention services.”
Commissioning in the primary care sector provides an opportunity to bring about the reform the health system needs. This does not always require procurement of additional services, but reorganising existing services. Commissioning provides us with a tool to reorientate the health system away from acute and episodic care towards prevention, self-care and greater coordination between the hospital and primary care sectors.
An early success story
A great example of this is our Hunter New England Diabetes Alliance model of care. This model is funded by the PHN and the HNE Local Health District and moves specialist services that usually happen in a hospital outpatient clinic to the General Practice. Here, the Endocrinologist, GP, Diabetes Educator and Practice Nurse all work together with the patient to identify outcomes and make a plan to achieve them.
This collaborative model of care has allowed cross organisational sharing of skills, knowledge and resources to develop a person centred model of care that is efficient, cost effective and sustainable.
A key to the model’s success is that it is based on the quadruple aims of healthcare. That is, it is improving the health of our population and improving their access to health care, reducing the future cost to the system by avoiding long term complications, improving the healthcare experience of patients (including reducing the number of patients at very high risk of hospital admission by 60%), and maximising the value we are spending across the whole system. Finally our evaluation shows 100% of clinicians enjoy working within this model.
Our experience so far with commissioning is that it is making us think more about the needs of individual patients and the perspective of the whole system.
Optimising resources, improving care
We believe there is a danger in viewing commissioning from the perspective of the existing players operating the health system. When this happens, it’s very easy to make commissioning decisions based on the existing pattern of service provision and the existing financial and organisational structures.
When we start to think about commissioning based on the needs of individual patients, it rapidly becomes clear how poorly integrated the delivery of health care really is, and how confusing this can often be for patients.
What we really want to do is to optimise the resources across the entire health care system in order to wrap services around patients seamlessly and deliver the outcomes that really matter for them. We believe commissioning, if done correctly, will allow us to do this.
Jay Rebbeck is Manager Director, Rebbeck Consulting
Scott White is Communication Manager, Hunter New England Central Coast PHN
Catherine Turner is Executive Manager, Quality, Commissioning and Improvement, Hunter New England Central Coast PHN