Ensuring the delivery of healthcare as safely as possible has become top priority for the NHS. The commissioners have an important role to play in planning and monitoring services on the basis of quality and outcomes to restore primum non nocere (first, do no harm)as a policy to its rightful place in the health system. But how should commissioners set about their task?
The end of the 20th century may well be seen as marking the decline of one era in healthcare and the rise of a new era in which excellent commissioning is required to meet the challenges of increasing life expectancy, changing patterns in disease and developments in treatments and technology. Advances in treatment and technology together with the increasing expectation of society mean that healthcare costs are being driven relentlessly upwards. A larger proportion of GDP is being consumed by healthcare worldwide and the UK faces the same challenge as numerous other countries. How to make the best use of the resources being committed to improve health services and health outcomes for its citizens.
The need for effective use of resources is coupled with a greater desire for quality. The ‘information society’ is rejecting the paternalism of the 20th century health system and increasingly arming itself with readily accessible insights and knowledge from the World Wide Web as to what constitutes not only effective but also safe, high quality care.
In these circumstances, as societies change and people’s expectations rise, health systems must adapt and evolve to meet these changing needs and new challenges.
The publication of To Err is Human in 2000 by the Institute of Medicine and An Organisation with a Memory in the same year by the Department of Health in the UK marked increasing awareness of the importance of and need to address safety in modern, complex health systems. Momentum has grown following these publications, spreading understanding of the important need to address safety in healthcare throughout the professions and public. The National Patient Safety Forum, set up following the publication of Safety First, jointly chaired by the Chief Executive of the NHS in England and the Chief Medical Officer, signals the highest leadership and priority the NHS is giving safety for patients.
Fundamental to improving safety is the realisation that it is not, predominantly, the responsibility of an individual. Neither is it solely attributable to a team. Both, of course, do have responsibility for safety: in a complex and demanding environment, excellent team work will improve safety. However, there is abundant evidence to demonstrate that the best way to drive improvements in safety is through ensuring that the systems and processes being used by organisations make safety a priority. How can that be engendered? What will ensure a focus on safe systems and processes?
In any industry, regulation has a vital role to play. Alongside an increased awareness of the need to design health systems that are safe, there has been an increase in regulation as well. In the UK, the Commission for Health Improvement was replaced by the Healthcare Commission, which is shortly due to be replaced by the Care Quality Commission. Each reorganisation has expanded the reach of the regulator. However, regulation alone will not deliver a safe system. There is an old saying that ‘he who pays the piper calls the tune’. Commissioners who finance the system, alongside regulators, have a critical role in improving patient safety as well as securing the most effective use of resources.
The need for better commissioning has been recognised in the UK and the Department of Health in England has launched an ambitious programme to develop ‘World Class Commissioning’.
For the first time, a vision and defined set of competencies have been clearly articulated for commissioners.
Several of these competencies have direct relevance to improving patient safety, for example:
Recognised as leaders of the local health system.
As leaders of the health system, commissioners have a vital role in signalling their intention to prioritise and value safety; to embed and ensure Primum non nocere (First, do no harm). Organisations move in the direction of the questions asked of them. Commissioners need to ask the right questions throughout their planning, procurement and performance management of the health system. This is a cultural shift in what has, traditionally, been a provider-led system. Commissioners must develop skills to lead the health system and it is well established that leaders who champion safety will improve safety.
Proactively seek and build continuous and meaningful engagement with the public and patients, to shape services and improve health.
Shaping health services that deliver safe care inevitably demands changes, which, unless set in context, communicated and explained, may well be opposed by communities and individuals. Parties with vested interests will also oppose change that threatens them and may seek to manipulate public opinion. Commissioners need to understand this and ally themselves with the public and patients they serve;
otherwise, reconfigurations for safer services may be delayed or prevented, leading to avoidable harm.
Patients have another powerful and often underutilised role which commissioners could and should harness. The importance of the patient story has been used by Sir Liam Donaldson, Chief Medical Officer, very effectively to illustrate and engage the public and professionals in safety. The National Patient Safety Agency through its work on encouraging reporting of incidents from organisations, staff and the public, is alerting the health system to issues that need addressing. Commissioners need to be friendly with patients and proactively seek out their views and also make sure that the systems are in place to receive their complaints.
Lead continuous and meaningful engagement with clinicians to inform strategy, and drive quality, service design and resource allocation.
Professor Chris Ham from the Health Services Management Centre at Birmingham University in England describes an ‘inverted pyramid of power’ which exists in any health system due to the important role that clinicians play in decision-making and committing resources. Doctors, nurses and allied professionals, with their close contacts with patients, could help commissioners in effectively implementing the safety procedures. Hence, commissioners should work in close coordination with clinicians and ensure that they are committed to improve safety. Commissioners need to work with and align the decisions they make with professional values and insights, to stimulate a cycle of continuous improvement. This bottom-up approach to influence commissioning has been exemplified by the recent review of the NHS in England led by Lord Ara Darzi, who is not only a health minister but also a practising surgeon.
Effectively manage systems and work in partnership with providers to ensure contract compliance and continuous improvements in quality and outcomes.
In order to improve patient safety, commissioners should work closely with their providers. World class commissioning is unlikely to be of any use unless it supports world class provision. Commissioners must work collaboratively with their provider organisations to understand barriers which need to be overcome and incentives and sanctions required to manage the health system appropriately and safely. To do this well requires effective use of information. Quality improvement is nourished by information but that information needs to be compelling—the sort of information which will stimulate change in systems and behaviour. Astonishingly, the NHS spends one hundred times more on research than it does on audit. Feedback in the form of case studies, significant event reviews, audit or the other established methodologies for quality improvement needs to be valued and supported by commissioners. Embedding them within the contracting process and working with clinicians to identify which measurements will drive improvement must be integral to deciding how to invest, another important competency.
Making sound financial investments to ensure sustainable development and value for money.
Ultimately, commissioners have to create an understanding that safer, better quality care is also cost-effective care.
Information alone does not provide answers but helps the right questions to be asked. The work being done nationally in the UK by the NHS Institute for Innovation and Improvement is providing commissioners with a wealth of information. The question is; how is such information to be used? Surely it means collecting and using information for improvement rather than for judgement. This is perhaps the most difficult and biggest challenge to commissioners as there is constant fear among organisations and professionals that this information may be misused. There appears to be a predominant culture in many health systems to simply use information for judgement in an adverse and confrontational way. This needs to change. Therefore, commissioners should support a system that is not driven by fear but by a continuous drive to improve safety and outcomes.
Crossing the Quality Chasm (Institute of Medicine 2001) has an appendix entitled Redesigning Health Care with Insights from the Science of Complex Adaptive Systems.
Commissioners need to become adroit at using their levers and those exerted by other agencies in order to competently influence the complexities of the healthcare system they are shaping, to obtain safe and effective services, delivering the best possible outcomes for their customers.
Providers who understand this new context and rise to the challenge of working collaboratively with commissioners will flourish and prosper and, most important of all, patients will benefit.
Martin McShane has had over 20 years of frontline clinical experience. Supported by the NHS, he developed an interest in commissioning. He is currently working for NHS Lincolnshire which commissions services for 750,000 people with a budget of £1 billion. He is a member of the NHS National Patient Safety Forum.