Ten priorities for commissioners: Transforming our health care system summary

Updated in June 2015 to reflect changes to the NHS from 1 April 2013.

As health care commissioners are faced with the most challenging financial and organisational environment seen in decades, we set out ten priorities for action to help commissioners transform the health care system.

1. Active support for self management

What is it?

Self-management support can be viewed in two ways: as a portfolio of techniques and tools to help patients choose healthy behaviours; and as a fundamental transformation of the patient-caregiver relationship into a collaborative partnership (de Silva 2011).

Why is it important?

  • Around 15 million people in England have one or more long-term conditions. The number of people with multiple long-term conditions is predicted to rise by a third over the next ten years (Department of Health 2011c).
  • People with long-term conditions are the most frequent users of health care services, accounting for 50 per cent of all GP appointments and 70 per cent of all inpatient bed days.
  • Treatment and care of those with long-term conditions accounts for 70 per cent of the primary and acute care budget in England (Department of Health 2011c).
  • At the heart of the chronic disease management model (Wagner et al 1996) is the informed, empowered patient with access to continuous self-management support.
  • Around 70-80 per cent of people with long-term conditions can be supported to manage their own condition (Department of Health 2005).

What is the impact?

  • Self-management has potential to improve health outcomes in some cases, with patients reporting increases in physical functioning (Challis et al 2010).
  • Self-management can improve patient experience, with patients reporting benefits in terms of greater confidence and reduced anxiety (Challis et al 2010).
  • Self-management programmes have been shown to reduce unplanned hospital admissions for chronic obstructive pulmonary disease and asthma (Purdy 2010) and to improve adherence to treatment and medication (Challis 2010), but evidence that this translates into cost savings is more equivocal. A cost analysis performed in the United States did indicate that expenditure in other parts of the system can be reduced (Stearns et al 2000).

How to do it

There are a number of well-established self-management programmes that aim to empower patients to improve their health. A review of the evidence has highlighted the importance of ensuring the intervention is tailored to the condition (de Sliva 2011). For example, structured patient education can be beneficial for people with diabetes, while people with depression may benefit more from cognitive and behavioural interventions.

Recent work conducted by the Richmond Group of Charities and The King's Fund (2012) called for patients to be offered the opportunity to co-create a personalised self-management plan which could include the following:

  • patient and carer education programmes
  • medicines management advice and support
  • advice and support about diet and exercise
  • use of telecare and telehealth to aid self-monitoring
  • psychological interventions (eg, coaching)
  • telephone-based health coaching
  • pain management
  • patient access to their own records.

Useful resources

2. Primary prevention

What is it?

Taking action to reduce the incidence of disease and health problems within the population, either through universal measures that reduce lifestyle risks and their causes or by targeting high-risk groups.

Why is it important?

  • More systematic primary prevention is critical in order to reduce the overall burden of disease in the population and maintain the financial sustainability of the NHS. While prevention in childhood provides the greatest benefits, it is valuable at any point in life.
  • It is estimated that 80 per cent of cases of heart disease, stroke and type 2 diabetes, and 40 per cent of cases of cancer could be avoided if common lifestyle risk factoes were eliminated (WHO 2005).
  • Common lifestyle risk factors cluster in the population (Buck and Frosini 2012), which has a dramatic effect on life expectancy (Khaw et al 2008). Addressing this clustering, and its socio-economic determinants, is likely to reduce inequalities and improve overall population health.

What is the impact?

  • Primary prevention is an excellent use of resources compared with many treatments. Of more than 250 studies on prevention published in 2008, almost half showed a cost of under £6,400 per quality-adjusted life year and almost 80 per cent cost less than the £30,000 threshold used by the National Institute for Health and Clinical Excellence for cost-effectiveness (van Gils et al 2010).
  • More systematic primary prevention in general practice has the potential to improve health outcomes and save costs (Health England 2009). For example, five minutes of advice in a general practice setting to middle-aged smokers to quit smoking can increase quit rates and save £30 per person for a cost of £11 per person.
  • Community-level campaigns to improve health behaviours, such as No Smoking Days, have been found to be very cost-effective (£82 per life year gained) (Kotz et al 2010).

How to do it

Evidence-based interventions include: supporting individuals to change behaviours, for example, through brief advice during a consultation; systematic community interventions in schools to reduce childhood obesity; and regulatory actions such as controlling the density of alcohol outlets (Campbell et al 2009).

In many areas, a strategic approach using a combination of interventions at the individual and societal level is likely to be most effective. For example, NHS Knowsley has had a major impact on smoking rates in disadvantaged communities through cross-partnership action including targeting illicit toboacco sales, reducing smoking in pregnancy, and providing drop-in clinics.

These approaches often require new ways of engaging with communities to ensure they reach those in greatest need. Social marketing techniques can improve the effectiveness of interventions by tailoring interventions to the needs of specific individuals or groups.

NHS England, acting in its new role as the single purchaser of NHS primary care, has an important opportunity to ensure that primary prevention is implemented systematically and at scale.

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3. Secondary prevention

What is it?

Systematically detecting the early stages of disease and intervening before full symptoms develop – for example, prescribing statins to reduce cholesterol and taking measures to reduce high blood pressure.

Why is it important?

  • Secondary prevention is based on a range of interventions that are often highly cost-effective and that, if implemented at scale, would rapidly have an impact on life expectancy.
  • There is substantial variation between practices in the systematic implementation of approaches towards secondary prevention – for example, use of disease registers. Only a minority of patients receive all recommended interventions.
  • Evidence suggests that this is an area where the 'inverse care law' applies and those in greatest need are least likely to receive beneficial services.
  • Identifying those at risk and intervening appropriately is one of the most effective ways in which GPs can reduce the widening gaps in life expectancy and health outcomes (Marmot Review 2010).

What is the impact?

  • Successful secondary prevention would have a major impact on health outcomes, in terms of improvement in life expectancy and reduction in complications.
  • Modelling by the Department of Health (2009) has shown that systematic and scaled-up secondary prevention is a cost-effective, clinically significant and fast way to tackle inequalities in health in local areas. The National Audit Office (2010) suggests that improving cholesterol levels and hypertension control have not been adopted at a sufficient scale. If they were, they would have a significant impact on inequalities.
  • Cost savings are likely to accrue over the medium term, as patients are prevented from experiencing a wide range of adverse events as their life expectancy lengthens.

How to do it

Secondary prevention largely involves the systematic application of standard, low-technology interventions. The key actions for commissioners are:

  • ensuring appropriate coverage of key secondary preventive interventions and processes including managing disease registers systematically by modelling expected versus actual prevalence and incidence, and thereby identifying practices where improvement is needed
  • systematic screening, where appropriate and known to be cost-effective
  • ensuring systematic control of hypertension, cholesterol and diabetes among clinical commissioning group's populations
  • working systematically with local authorities and other partners to ensure secondary prevention forms part of a broader strategy on public health
  • working with community and voluntary sector groups to both develop more tailored joint strategic needs assessments and health and wellbeing strategies, and to engage with and provide services to patients who are not reached by mainstream health services.

Useful resources

4. Managing ambulatory care sensitive conditions

What is it?

Ambulatory care sensitive (ACS) conditions are chronic conditions for which it is possible to prevent acute exacerbations and reduce the need for hospital admission through active management, such as vaccination; better self-management, disease management or case management; or lifestyle interventions. Examples include congestive heart failure, diabetes, asthma, angina, epilepsy and hypertension.

Why is it important?

  • Despite admission being largely preventable, a significant proportion of all acute hospital activity is related to ACS conditions. In England ACS conditions accounted for 15.9 per cent of all emergency hospital admissions in 2009/10 (Tian et al 2012).
  • There is significant variation in how effectively ACS conditions are managed – emergency admissions per head may vary more than two-fold between local authority areas after adjusting for the differences in age, gender and deprivation (Tian et al 2012).
  • These admissions are costly. The total cost to the NHS in 2009/10 was estimated at £1.42 billion for a core set of 19 ACS conditions (Tian et al 2012).

What is the impact?

  • Maintaining wellness and independence in the community prevents deterioration in conditions and therefore results in better health outcomes.
  • Emergency admissions to hospital are distressing, so better management that keeps people well and out of hospital should lead to a better patient experience.
  • According to The King's Fund estimates, emergency admissions for ACS conditions could be reduced by between 8 and 18 per cent simply by tackling variations in care and spreading existing good practice. This would result in savings of between £96 million and £238 million (Tian et al 2012). This calculation may significantly underestimate potential savings as admission rates in all areas are significantly above what should be achievable.

How to do it

Early identification of ACS patients is crucial if their management is to be successful. GPs are well placed to do this through the use of risk stratification tools and clinical decision support software within GP practices. Some progress can be made through relatively simple measures such as expanding vaccination, where available, to prevent the onset of a condition. For other ACS conditions (chronic and acute aggravated conditions), commissioners will need to encourage active disease management.

A previous review of evidence (Purdy 2010) suggests that the following evidence-based interventions for avoidable admissions should be implemented and evaluated locally:

  • disease management and support for self-management for those with long-term conditions
  • telephone health coaching
  • other behavioural change programmes to encourage patient lifestyle change.

The review also suggested that improvements in the quality of primary and secondary care are needed, for example:

  • increase continuity of care with GP
  • ensure local, out-of-hours primary care arrangements are effective
  • for those with acute aggravated conditions, ensure there is easy access to urgent care
  • conduct early senior review in A&E, and implement structured discharge planning.

Useful resources

5. Improving the management of patients with both mental and physical health needs

What is it?

Developing a more integrated response to people with both mental and physical health problems, in particular supporting people with common mental health problems (such as, depression or anxiety) alongside a physical long-term condition.

Why is it important?

  • At least half of all people with long-term conditions suffer from multiple co-existing conditions. Mental health problems are one of the most common forms of co-morbidity, particularly among people from the most deprived population groups (Barnett et al 2012).
  • Mental health problems interact with physical health and can trigger or severely exacerbate other conditions. For example, depression has been associated with a four-fold increase in the risk of heart disease (Osborn et al 2007) and a three-and-a-half-fold increase in mortality rates after heart attack (Lesperance et al 2002).
  • Between 12 and 18 per cent of all NHS expenditure on long-term conditions is estimated to be linked to mental health problems (Naylor et al 2012). Across a range of conditions, each patient with co-morbid depression costs health services between 30 and 140 per cent more than equivalent patients without depression (Welch et al 2009; Melek and Norris 2008).
  • Unidentified mental health problems often underlie 'medically unexplained symptoms', which cost the NHS around £3 billion each year and cause significant distress to patients (Bermingham et al 2010).

What is the impact

  • Improving the way we respond to co-morbid physical and mental health problems would have a high impact in terms of patient experience and clinical outcomes, since both of these are substantially poorer relative to those for people with a single condition (Naylor et al 2012).
  • There could also be a significant impact on costs. Integrated models of disease management have been found to deliver savings four times greater than the investment required (Howard et al 2010), as have enhanced models of liaison psychiatry in acute hospitals (Parsonage et al 2012).

How to do it

Some of the changes required would be relatively simple for commissioners to implement, while others would be more complex as they involve redesigning the interface between multiple providers. Specific priorities include:

  • improving identification of mental health needs among people with long-term conditions
  • strengthening data systems to support more systematic coding and recording of mental health needs
  • commissioning services that improve the interface between primary care, mental health and other professionals, for example, based on collaborative care models recommended by National Institute for Health and Clinical Excellence (2009).
  • strengthening disease management and rehabilitation programmes by including psychological or mental health input
  • using CQUIN payments and other targeted quality incentives to encourage providers to develop innovative forms of liaison psychiatry within acute hospitals, care homes and elsewhere
  • expanding Improving Access to Psychological Therapy services to support people with co-morbid long-term conditions, in line with government ambitions
  • improving mental health skills in general practice using training programmes developed specifically for primary care professionals.

Useful resources

6. Care co-ordination through integrated health and social care teams

What is it?

Creating patient-centred care that is more co-ordinated across care settings and over time, particularly for patients with long-term chronic and medically complex conditions who may find it difficult to 'navigate' fragmented health care systems.

Why is it important?

  • Co-ordination of care for people with complex chronic illness is a global challenge. Driven by broad shifts in demographics and disease status, long-term conditions absorb by far the largest, and growing, share of health care budgets (see Active support for self-management).
  • Co-ordination of care for patients with complex needs and long-term illness is currently poor (The King's Fund 2011), and those with long-term conditions have a lower quality of life (Department of Health 2011).

What is the impact?

  • Robust evidence on health outcomes is limited, but improved care co-ordination can have a significant effect on the quality of life of older frail people and people with multiple long-term conditions (Hofmarcher et al 2007).
  • Highly integrated primary care systems that emphasise continuity and co-ordination of care are associated with better patient experience (Starfield 1998; Bodenheimer 2008).
  • Impact on costs and cost-effectiveness is less easy to predict and is likely to be low in the short term given the upfront investments required. However, health systems that employ models of chronic care management tend to be associated with lower costs, as well as better outcomes and higher patient satisfaction (Singh and Ham 2005).

How to do it

There is no one model of care co-ordination, but evidence suggests that joint commissioning between health and social care that results in a multi-component approach is likely to achieve better results than those that rely on a single or limited set of strategies (Singh and Ham 2005; Powell Davies et al 2008; Kodner 2009). Some of the key components (The King's Fund 2011) are:

  • a move to community-based multi-professional teams based around general practices that include generalists working alongside specialists
  • a focus on intermediate care, case management and support to home-based care
  • joint care planning and co-ordinated assessments of care needs
  • personalised health care plans and programmes
  • named care co-ordinators who act as navigators and who retain responsibility for patient care and experiences throughout the patient journey
  • clinical records that are shared across the multi-professional team.

Care for Older People in Torbay provides a good example of the kind of change required. Torbay established five integrated health and social care teams organised in localities aligned with general practices. Care co-ordinators support older people following an emergency hospitalisation, helping them to receive the intensive support required to enable them to live at home.

Northamptonshire Integrated Care Partnership focused on helping patients remain independent for longer and creating personalised care plans for high-risk individuals that aimed to reduce admissions to hospital. It developed a new community-based service for patients at the end of life and a multidisciplinary care service for older people to support independent living in the community.

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7. Improving primary care management of end-of-life care

What is it?

Within primary care, improving the systematic identification of patients who are at the end of life, and then providing the appropriate support; in particular, improving the co-ordination of care, continuity, quality of communication, and the provision of bereavement care.

Why is it important?

  • Two-thirds of people would prefer to die at home, but in practice only about one-third of individuals actually do (Higginson 2003).
  • The annual number of deaths in England and Wales is expected to rise by 17 per cent from 2012 to 2030, and the average age at death is also set to increase markedly (Gomes and Higginson 2008).
  • The costs of caring for people at the end of their lives is estimated to run into billions of pounds (National Audit Office 2008). Care for the 27 per cent who die from cancer is around £1.8 billion in the last year of their life, or £14,236 per patient (Hatziandreu et al 2008).
  • Wide variations exist in the quality of end-of-life care across England. Spending by primary care trusts (PCTs) on palliative care has varied from £154 to more than £1,600 per patient (National Audit Office 2008).

What is the impact?

  • Research by The King's Fund has identified many examples of how improvements in end-of-life care can have a high impact on patient experience as well as the experience of family members and carers (Addicott and Ross 2010).
  • Some evidence suggests greater co-ordination of care can improve quality without incurring any additional costs (Addicott and Dewar 2008). There may be some scope to make cost savings, particularly through a reduction of unnecessary admissions into the acute setting.

How to do it

End-of-life care is provided in a variety of settings by a wide range of professionals. To meet patients' needs a whole-systems approach is needed that co-ordinates care across professional and organisational boundaries (Addicott and Ross 2010). GPs are in a central position to do this.

Commissioners should be driving a whole-systems approach that focuses on the availability of a range of services across the care pathway, such as:

  • facilitation of discharge from the acute setting
  • rapid response services during periods out of hospital
  • centralised co-ordination of care provision in the community
  • guaranteeing 24/7 care.

The integration of services is currently hindered both by the way that end-of-life care is funded and by the contracting mechanisms used. Commissioners should contract for a pathway or package of care in order to encourage providers to work together to deliver a more streamlined service. However, packages should be structured so that they can cater for a range of individual needs and preferences (Addicott and Hiley 2011).

Pooled budgets offer the most concrete approach for encouraging integration across providers. Commissioners should start small in their approaches to using pooled budgets, and focus on areas where the relationships, common pathways and data exist to support such a model.

It will also be important to ensure that end-of-life care features in any care pathway to ensure that we shift the focus beyond terminal cancer.

Useful resources

  • The Gold Standards Framework (GSF) is a systematic, evidence-based approach to help clinicians to a) identify patients in the final years of life, b) assess the needs, symptoms and preferences of those patients, and c) plan care on that basis, enabling patients to live and die where they choose.
  • The National End of Life Care Programme provides policy guidance, and education and training to health and social care services across all sectors in England to improve end-of-life care for adults.
  • The Liverpool Care Pathway for the dying patient is an integrated care pathway that is used at the bedside to drive up sustained quality of the dying in the last hours and days of life.

8. Effective medicines management

What is it?

Medicines management supports better and more cost-effective prescribing in primary care, as well as helping patients to manage medications better. Good medicines management can help to reduce the likelihood of medication errors and hence patient harm.

Why is it important?

  • There is a considerable body of evidence from the point of view of patient safety, service efficiency and cost that medicines management needs to be improved.
  • In 2011, 961.5 million prescription items were dispensed in primary care alone at a cost of £8.8 billion (Information Centre 2012).
  • Medication errors occur in up to 11 per cent of prescriptions, mainly due to errors in dosage (Sanders and Esmail 2003).
  • Around 7 per cent of all hospital admissions have been attributed to, or associated with, adverse drug reactions – with up to two-thirds of these being preventable (Pirmohamed et al 2004). Adverse reactions are particularly common among vulnerable groups, such as, frail older patients in nursing homes (Gurwitz et al 2005).
  • Between one-third and one-half of all medication prescribed for long-term conditions are not taken as recommended (Nunes et al 2009).

What is the impact?

  • Improved medicines management could be expected to have a high impact in terms of patient experience and health outcomes. There is good evidence that guidance and peer review can support improvements in the quality of prescribing (Duerden et al 2011), although significantly improving patient compliance may be more difficult (Haynes et al 2008).
  • The impact on costs could also be substantial, given the levels of drug wastage and the high numbers of preventable drug-related emergency hospital admissions. Standardising prescribing practices for certain treatments (such as low-cost statins) could save the NHS more than £200 million a year (NAO 2007).

How to do it

There are a number of techniques available that GPs will be in a prime position to implement:

  • medication reviews, usually in general practice, that seek to ensure prescribing standards are being met, for example, through practice-based audits linked to peer review of prescribing practices and outcomes
  • use of IT and decision-support tools to support best practice in prescribing by professionals
  • pharmacist- and nurse-led interventions that provide educational information and outreach services to reduce prescribing and monitoring errors among high-risk patients (Avery 2010)
  • use of pharmacy technicians to support practices to improve their prescribing practice by conducting systematic audits, evaluating patients and recommending changes to medication
  • improved systems to support safe transfer of information on patient medication at admission and discharge
  • providing clinicians with benchmarked information on prescribing performance.

Useful resources

9. Managing elective activity-referral quality

What is it?

Managing elective (planned) hospital activity by systematically reviewing and auditing referrals with a view to benchmarking against other practices and improving referral quality and by ensuring patients are fully involved in decision-making.

Why is it important?

  • GPs make more than nine million referrals to hospitals for elective care each year. These then trigger an annual spend of more than £15 billion in the NHS (McKinsey 2009). As a result, control over a significant proportion of CCG's commissioning budget lies in the hands of their member practices.
  • Referral rates to a particular specialty within a single area vary as much as ten-fold between GPs (Creed et al 1990; Ashworth et al 2002). A wide variety of factors account for this variation, clinical and non-clinical (Foot et al 2010). The available research suggests that a substantial proportion of activity is discretionary and could be avoided or redirected.
  • There are also patients who need a referral but fail to receive one. For example, lack of or late referral is thought to be a key driver of poor survival rates for cancer (Department of Health 2011b).
  • There is evidence to suggest that the quality of referral letters could be improved in some cases (Foot et al 2010). The absence of key information can make it difficult to triage referrals appropriately and identify the best destination for the referral (Speed and Crisp 2005).
  • GPs, patients and specialists do not always share a common understanding of why a referral is being made, for example, whether it is primarily for diagnosis, investigation, treatment or reassurance (Grace and Armstrong 1986, Broomfield et al 2001, Molloy and O'Hare 2003).

What is the impact?

  • Given the link between poor outcomes and late referral, particularly for cancer, improving referral quality should have an impact on health outcomes in some cases.
  • Improving the quality and appropriateness of referral would have an impact on patient experience by avoiding unnecessary visits and improving the timeliness of treatment.
  • There is some scope to reduce costs by avoiding unnecessary referrals. However, this needs to be balanced against the likelihood that improved review and audit processes would also identify under-referral in some clinical areas.
  • Referral audit can help to identify training needs and thereby improve the quality and cost-effectiveness of clinical care.

How to do it

Clinical commissioning groups and the locality groups beneath them provide a structure through which active referral review can take place, within the context of wider audit programmes that should become day-to-day business for practices in the future. Referral review could involve:

  • systematic use of comparative information about GP and practice referral rates by specialty supported by more detailed audits at practice level including discussion of a sample of referrals to examine their content and appropriateness
  • generalists and specialists agreeing redesigned elective care pathways including consultant-to-consultant referral protocols.

Approaches based on review and audit are recommended over the establishment of referral management centres, which can add a significant overhead cost to each referral, fail to address individual practice deficits, and introduce new clinical risks (Imison and Naylor 2010).

Useful resources

  • The King's Fund report on referral management, Referral management: lessons for success (Imison and Naylor 2010), describes the strengths and weaknesses of the different approaches to referral management and provides some practical suggestions of ways to support the referral process. There is also an accompanying case study providing a detailed description of how one practice has introduced referral management and the impact that it has had.
  • A directory of referral and demand management resources complied by Quality MK

10. Managing urgent and emergency activity

What is it?

Developing an integrated approach to urgent and emergency care, particularly emergency medical admissions to hospital, involving hospitals, community, primary and ambulance services through joint service planning and sharing of clinical information across different agencies.

Why is it important?

  • Urgent care services are currently often highly fragmented and generate confusion among patients about how and where to access care (Lattimer et al 2010).
  • Patients are frequently admitted to hospital when this is not clinically justified because of a lack of alternative options.
  • Poor sharing of information as patients move between different providers is a cause of significant failures of care (Gandhi 2005).
  • The growth of new forms of urgent care, such as walk-in and urgent care centres, has failed to reduce A&E attendances (Cooke et al 2004). These grew by 30 per cent between 2003/4 and 2011/12 (Department of Health 2011a).
  • New forms of urgent care have also failed to reduce emergency admissions, which continue to grow, rising by 5 per cent between 2008/9 and 2011/12 (Department of Health 2011d; 2012).

What is the impact?

  • Addressing poor practice, improving care continuity, and reducing the numbers admitted to hospital could have a significant impact on health outcomes.
  • Making the urgent care system easier to navigate would improve patient experiences substantially.
  • Integrated urgent and emergency care services that manage demand more effectively have the potential to be significantly more cost-effective than existing arrangements.

How to do it

Although the impact could be highly positive, redesigning the urgent and emergency care system is likely to be highly challenging. Specific actions for commissioners could include:

  • providing effective signposting to help patients choose the right service
  • ensuring that hospital and community services can adjust service levels in response to changes in demand, so that need and provision are kept in balance
  • ensuring that A&E departments adopt best practice for handling 'majors' including early senior review
  • ensuring that hospitals and local authority social service and housing departments work effectively together to reduce delayed discharges and shorten lengths of stay
  • mapping and analysing patient flows around the system to identify bottlenecks and the scope for changing pathways to reduce the use of hospitals and to ensure that there is sufficient capacity across the health and social care system.

Useful resources

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