Putting people at the centre of GP commissioning …...Page | 2 Putting people at the centre of GP commissioning: experience led commissioning “It is not often you hear about truly

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Putting people at the centre of GP commissioning:

experience led commissioning

“It is not often you hear about truly innovative approaches. This is one.

Its potential to support delivery of patient centred commissioning is exciting.”

Dr James Kingsland, National Clinical Commissioning Lead, Department of Health

“This approach offers a really effective way of incorporating users’ views

into the commissioning process. We look forward to its wider use and

adaptation across the country.”

Dr Brian Fisher, NHS Alliance Lead for Patient and Public Involvement

"How we bring patient experience to bear on commissioning decisions is

a fundamental question about which we have very little clarity.

Experience led commissioning is a fascinating and rich model that seeks to

provide that clarity, and now needs to be tried in the field".

Jeremy Taylor, Chief Executive, National Voices

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Policy context

The publication of the recent White Paper Equity and excellence: liberating the NHS1 signals

that in less than two years, GP commissioning consortia will have full responsibility for

commissioning the vast majority of NHS care.

In this transitional period, the challenge is working out how GP commissioning will differ

from what has gone before and what good GP commissioning looks like. Doing this,

alongside managing transition, is a huge challenge. It requires the collective wisdom of all

those who have insights to share.

We believe this is a time of great opportunity and provides the chance to do things

radically differently. The White Paper emphasises the priority it attaches to ‘putting

patients and the public first’, and notes that:

“The NHS....scores relatively poorly on being responsive to the patients it serves. It

lacks a genuinely patient-centred approach in which services are designed around

individual needs, lifestyles and aspirations. Too often, patients are expected to fit

around services, rather than services around patients. [section 1.9]

Healthcare systems are in their infancy in putting the experience of the user first,

and have barely started to realise the potential of patients as joint providers of

their own care and recovery. Progress has been limited in making the NHS truly

patient led. [section 2.2]”

It signals that the NHS must live by the motto ‘no decision about me without me’. This

means, by implication, that GP commissioning must do the same since the decisions that GP

commissioners make will directly impact on the care of patients.

Transparency in Outcomes - a framework for the NHS 2 sets experience alongside

effectiveness and safety as the three domains of quality against which the NHS will be

monitored and around which improvement will focus.

1 Department of Health. (2010) Equity and excellence: liberating the NHS. London: Department of Health

2 Department of Health. (2010) Transparency in outcomes – a framework for the NHS. London: Department of Health

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To date, commissioning management processes and approaches have, for the most part,

fallen short of putting the patient’s perspective at the centre of decision making. Now is the

time for create new ways of working

Research shows that sustaining substantial change in patient experience requires the right

organisational strategy; engaged leadership; the right culture; regular measurement and

performance feedback, and experience of interpreting and using survey data

Perhaps because it has too often been seen as a separate process or work stream within the

system rather than the central philosophy that drives NHS thinking, improving care

experience and involving people in commissioning has

commissioning management

tended to rely on the views of a small number of actively engaged local people.

We believe there needs to be

and patient focused means within commissioning. We propose that patient focus needs to

become an all encompassing philosophy that pervades the whole process, and every

decision commissioners make.

3Davies, E. et al. (2008) Evaluating the use of a modified CAHPS survey to support improvements in patient

lessons from a quality improvement collaborative. Health Expectations (2), pp 160



time for create new ways of working and address this.

t sustaining substantial change in patient experience requires the right


performance feedback, and experience of interpreting and using survey data

often been seen as a separate process or work stream within the


experience and involving people in commissioning has tended to work in parallel to

rather than being central to it. And often commissioners have


there needs to be a fundamental shift in thinking about what being responsive



decision commissioners make.

. (2008) Evaluating the use of a modified CAHPS survey to support improvements in patient

quality improvement collaborative. Health Expectations (2), pp 160-1



t sustaining substantial change in patient experience requires the right


performance feedback, and experience of interpreting and using survey data.3

often been seen as a separate process or work stream within the


in parallel to

. And often commissioners have


shift in thinking about what being responsive



. (2008) Evaluating the use of a modified CAHPS survey to support improvements in patient-centred care:

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We have developed an innovative approach to help commissioners and care managers to:

• Create the right organisational strategies;

• Engage leadership across the health economy;

• Drive cultural change;

• Effectively use performance feedback and survey data to improve experience

so that being experience-led becomes ‘the way we do things around here’.

We recognise that focusing on this may seem particularly challenging at a time of great

financial pressure. Yet in fact, our analysis of health experience research tells us that many

of things that matter most to people, including co-ordination and integration; information

and education are the very things that create a more efficient and joined up care system.

It is also important to remember that many of the things patients say they want most - such

as emotional support, kindness, human empathy and dignity - often cost little or nothing at

all.

And whilst improving patient experience does not always save money in easy to measure

ways, there is a well documented link between poor patient experience and poor outcomes

of care – and we know improved outcomes will reap both financial and social returns.

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Introducing experience led commissioning (ELC)

There is increasing interest in improving experience and a willingness to engage with this

agenda amongst providers and commissioners alike.

We believe we have found a way in which we can help people take an evidence based

approach and address what is ultimately a major cultural shift for some.

The package of management tool and processes we have developed, using the secondary

analysis of existing health experience research combine both commissioning and care

management ‘process’ tools with narrative based change and internal communication

management techniques that drive cultural change.

By holding health experience research up as a mirror to commissioners and providers, we

have observed that it helps commissioners remain focused and people-centred, and gives

them confidence that their decisions reflect what really matters to those using services.

In this way, the ELC process underpins and supports a change in organisational and

individual attitudes and beliefs, which we know to be the precursor to changed behaviour.

By setting out to win the hearts and minds of managers, professionals and staff as part of

successful commissioning of a good care, we believe we are creating a powerful programme

that fundamentally redefines what commissioning is about and will help the new system be

systematically patient centred from the start.

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The theoretical background to ELC

Experimental research on narrative persuasion theory4 5 finds that if a person becomes

absorbed in a story, the story is likely to have a significant impact on the person’s beliefs

and attitudes. Oral and written narrative accounts have the ability to capture the listener’s

imagination and create a bridge of empathic connection that illuminates the life-world of

another person. For this reason, narratives are a powerful way to engage commissioners

and care providers at a deep emotional level in thinking about health services from the

patient’s perspective, allowing the discovery of new paths to service improvement6 7 .

Detailed patient accounts of their experiences can reveal what patients value in existing

services, what patients do not value, and what matters to them most. Analysis of patient

experiences can identify barriers to accessing services, problems not previously recognised,

and solutions to problems that may not occur to people who are immersed in the process of

commissioning or service delivery8 9 .

Many NHS organisations are now successfully experimenting with ways of gathering

qualitative user views and using them to improve services. When we combine this with the

use of rigorous research with a broad sample of users and a full range of different

perspectives, it creates a powerful rationale for change.

4 Green MC & Brock TC. (2000). The role of transportation in the persuasiveness of public narratives. J Personality and Soc

Psychol. 79(5):701-21

5 Green MC, Strange JJ and Brock TC (eds.) (2002) Narrative impact: social and cognitive foundations. Mahwah NJ:

Lawrence Erlbaum Associates

6 Greenhalgh T, Russell J & Swinglehurst D. (2005) Narrative methods in quality improvement research. QSHC 14:443-449

7 Bate SP and Robert G. (2007) Bringing User Experience to Healthcare Improvement: the Concepts, Methods and Practices

of Experience-Based Design. Oxford: Radcliffe Publishing

8 Locock L. (2001) Maps and Journeys: Redesign in the NHS. Birmingham: University of Birmingham

9 Iles V & Sutherland K. (2001) Organisational change: a review for health care managers, professionals and researchers.

London: SDO

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What does ELC entail?

The hypothesis that underpins ELC is that unless you really understand the experiences of a

broad range of service users, you will tend to base commissioning decisions on assumptions,

personal beliefs and anecdotal experiences.

In a worst case scenario, one individual, shouting very loudly, could effectively succeed in

driving commissioners to make whole scale system change that may not be necessary or the

best use of public money – and may not even be viewed as important by the vast majority of

local service users and clinical staff. What is more, when a wealth of existing research

exists, there really is no need to use individual views as the basis of commissioning and

service design decisions.

You could say, we are creating an ‘evidence based’ approach to patient centred

commissioning and service design.

The Health Experiences Research Group (HERG) at the University of Oxford collects rigorous

qualitative interview studies on experiences of health and illness. The group has an archive

form of over 2,000 interviews covering more than 55 health conditions, all collected in the

last 10 years.

The research group collaborate with the DIPEx charity to publish analysis and carefully

selected extracts from the interviews on two websites: www.healthtalkonline.org and

www.youthhealthtalk.org, thus making the research directly available to the public, patients

families and carers. The archive is also an unrivalled source for secondary analysis of patient

experiences.

We believe that targeted secondary analysis of the HERG interview collections could provide

commissioners and service providers with narratives and robust insight data that improve

their ability to see their world through the eyes of service users.

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Beyond anecdote: understanding most people’s health experience

The interviews collected and analysed by HERG provide a rigorous, evidence-based

summary of patients’ experiences of a particular condition. Sampling ensures coverage of a

broad range of different types of people and different types of experience. We believe the

themes identified in these national studies cover very similar ground to what local people

would tell us matters most to them. To test this, we have conducted a scoping study,

comparing a ‘best in class’ PCT experience led commissioning process where the PCT

invested heavily in extensive local experience research in end of life care with a secondary

analysis of an existing HERG end of life care health experience data set10

, collected in line

with the high level qualitative research methodology used by the Health Experiences

Research Group11

.

The comparative thematic analysis across the two pieces of research showed that the vast

majority of experience themes identified in the local study had already been identified in

the national data set. The more extensive national study also identified several additional

themes in patient experiences that were not identified in the local study and that would also

be likely to be important for local patients, including preferences for palliative care and

where to die and the importance of advance refusals and getting affairs in order. Themes

identified in the local study that were not identified in the national study concerned aspects

such as local access and opening hours of particular local services.

This is encouraging. It suggests that combining:

• Secondary analysis of qualitative interview studies collected throughout the UK

• A targeted local programme of user and carer engagement underpinned by material

based on the national data; and

• Feedback and analysis of performance management data from local providers,

collected with the specific purpose of helping commissioners to understand the

quality of local services and what it is like to experience the local service, focusing

especially closely on the key touch points that we know impact on people’s service

experience

would enable commissioners to create a rigorous, integrated and vitally important, cost

effective approach to experience led commissioning that enjoys economies of scale where

it can; ensures a robust experience data set underpins commissioning, whilst enabling local

variations to be recognised, measured and addressed.

10

Calabrese J. (2010) A Comparison of Data on Patient Experiences of End of Life Care. Oxford: Green Templeton

College

11

http://www.healthtalkonline.org/Overview/Research

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Progress to date

National dataset: we have developed a standard process to undertake secondary analysis

of existing health experience research data sets to create generic condition specific ELC data

sets for commissioner and care providers to use.

These will help fast track clinicians’ and health managers’ understanding and ability to

become truly patient focused by increasing their ability to walk in the shoes of service users.

The next step to take this national work forward is attracting funding to undertake

secondary analyses and translate them into ELC data sets, and to do the original research to

plug a number of important gaps e.g. people’s experience of COPD and dementia.

We also need to create a sustainable way of providing and refreshing this data over time

and making it available for NHS commissioners and providers to use. Georgina Craig

Associates, HERG and University of Oxford and Green Templeton College are working

together to explore how best to do this.

We believe that these ELC data sets will form a key part of the commissioning support

information that GP commissioners will want and need to access to deliver patient centred

commissioning.

Local implementation process: We hypothesise that responding to and addressing the

critical touch points identified in the ELC data sets in a highly focused way will deliver the

vast majority of the quality improvement benefits from a patient’s perspective.

We also anticipate that many of these changes will be small, incremental and often low cost

or cost neutral for providers; yet could generate savings across the system.

This is borne out by examples of good practice we know of. For instance, Principia, a

Nottinghamshire based GP commissioning group found that when they used patient

interviews to inform their commissioning of COPD service, the fear they heard in people’s

voices when they talked about facing a weekend without access to a GP led them to

reassess the importance of commissioning additional community nursing. Following the

introduction of more community nursing support, unplanned admissions to hospital fell

significantly, and thus so did the overall cost of care. People’s fears were addressed and

their experience of care improved – and costs fell.

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We are working with existing and emerging GP commissioning groups to explore and scope

the local engagement elements of our programme. Issues we are scoping with GP

commissioners include:

• How does ELC change the quality of the questions commissioners ask?

• What kind of local user and carer engagement needs to happen to ensure we

validate and test the relevance of the national data fully with local health and service

experience and understand the similarities, differences and unique local issues?

• When should commissioners engage providers and how can providers help co design

their contracts so they focus on improving the quality of care experience?

• How can ‘must do’ performance management processes that are being developed

centrally be streamlined so that we minimise local commissioners’ management

work load, whilst ensuring they have the management data they need to truly judge

how well they are succeeding in commissioning providers to deliver a high quality

service experience?

• How do we effectively drive the cultural change necessary within local

commissioning and provider organisations to embed a patient centred approach and

make it ‘the way we do things around here’?

• How do we disseminate this work and scale it up across the country?

• How do we build on the evident interest and enthusiasm for learning from patients

and experiences of health care?

We are currently seeking funding to undertake the necessary scoping work to answer these

questions and test our prototype commissioning management and organisation

transformation tools, and ensure they can be adapted to any health condition by populating

them with the relevant ELC data set.

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Our prototype ELC commissioning process

The following diagram summarises our prototype process and the elements that

differentiate it from current commissioning:

ELC creates the possibility of incorporating robust national patient experience data in the

form of trigger films, narratives and commissioning management information to

systematically inform all four stages of the commissioning process.

ELC also adopts the principle of co-design and incorporates processes adapted from

experience based co design. This helps provide a framework for commissioners to engage

and work in partnership with users, carers and providers at critical points in the

commissioning design process to co create the commissioning plan. It also a shared vision

that is co-owned early on.

The practical implication of this is that commissioners can rationalise some of their provider

development and public engagement work and combine it with their work to improve care

experience, whilst demonstrating explicitly that they are driving quality improvement and

delivering at least three for the price of one! By default, it also demonstrates they are a

responsive commissioning body.

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Taking the building blocks of commissioning, here is a brief description of ELC:

• Needs assessment: The ELC approach sees commissioners combining public

health, socio economic, demographic, epidemiological and service usage data,

alongside any pre-existing local information about how people experience services

with the relevant national ELC data set, created using the condition specific

secondary analysis of qualitative interviews collected by HERG. These data sources

combined create a rich picture of local need. Once a national ELC data set is

available, it can be used by all GP commissioning groups that want to adopt an ELC

approach. ELC data is presented in a number of format, including: management

reports, narratives and triggers films. We then encourage commissioners to test

their assumptions about how a good experience should be, against the evidence

from experience research before they share their thinking with service users. The

second part of the ELC needs assessment process see commissioners discussing

the rich picture of local need and their emerging thinking on good experience with

service users. In a facilitated, collaborative workshop (pre-framed by a trigger film

and narratives drawn from the qualitative interviews), commissioners and users

and carers review what is known; ensure that there are no significant gaps in the

needs assessment AND have the opportunity to start to co-design what a good

care experience would feel like.

• Service design and specification: at this stage, commissioners, users and providers

engage in co design of a good care experience and discuss how high quality care

can be delivered in an integrated way. The output of this meeting is a shared vision

of ‘what good looks like’ and the critical factors for delivery. This output is co-

owned by commissioners, providers and users.

• Contracting: the next stage is for commissioners and providers to co-design the

contract that will deliver the desired outcomes. Focusing on a small number of

critical touch points that have been identified with users and carers as the biggest

priority for driving experience improvement during the previous stage, ELC sees

commissioners and providers jointly agreeing a performance management

framework that will systematically measure experience improvement. This

contracting process can be applied in the context of any willing provider, primary

contractor model or to design contractual mechanisms like CQUIN or other local

quality improvement frameworks.

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• Monitoring and review: ELC monitoring must deliver useful management data that

will support commissioning decision making during the review phase; and ideally it

will capture narratives of care because we know these are especially compelling

and drive change. A key objective of monitoring and review is to engage staff and

motivate them to further improve care experience. We also want our monitoring

tools to encourage reflective practice at both commissioner and provider level. We

envisage review as an annual process where commissioners, providers and users

come together; understand what has changed and what the data (which may

include national surveys, narratives, complaints and compliments) tells us about

how well we have succeeded in delivering the good experience all parties signed

up to 12 months ago. Because we anticipate the system will address on a relatively

small number of nevertheless critical touch points, our pilots will establish

a very focused process. It will also help all three parties identify and prioritise the

next areas for improvement before completing the circle and revisiting the needs

assessment phase.

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ELC and decommissioning

The current financial climate means that there is an increasing focus on decommissioning.

We believe that decommissioning is a natural process that falls out of a responsive health

care system. As technology advances, it is self evident that some services will become

obsolete.

ELC is equally powerful as decommissioning process. By providing insights into the benefits

people experience from accessing the service, it helps ensure that when a service is

decommissioned, the benefits the service delivers in terms of a good experience can be built

into the replacement service or delivered in a different, more cost effective way. An

example of how this might work is illustrated below in relation to follow up care for cancer

survivors. By redefining the commissioning challenge in terms of delivery reassurance, it

enables commissioners to think broadly about how reassurance can be delivered and costly

outpatient care decommissioned.

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The ELC Bonus: creating a common purpose and language

We believe (and have some emerging evidence) that ELC delivers additional benefits:

1. For many years, managers and clinicians have struggled to find a common language

to underpin joint working. We believe that an ELC helps articulate a shared vision

and thus addresses this. Our early experience shows that once managers and

clinicians have a common understanding of what it really feels like to be a service

user or carer (based on a strong evidence base of experience data) they have more

constructive discussions and ask different questions that focus on the shared goal of

improving the quality of care. We believe that ELC will engender greater co-

operation between managers and clinicians.

2. We have observed that when the NHS makes clinical care pathways the basis for

commissioning, people often become territorial about segments of the pathway,

believing they belong to them. When we chunk up and shift focus beyond clinical

care and towards designing a good experience of appropriate care, mind sets also

shift. Discussions focus on changing people’s experience of care and thus on

delivering real change at the front line. We are finding when discussions about

people’s experience are evidence based, clinicians, grounded in an evidence-based

culture are convinced to change their personal beliefs and behaviour.

3. Moving, compelling user and carer stories help break down barriers. Narratives

challenge assumptions. In our early experience, this leads to a more flexible attitude

and recognition that commissioners and providers may not fully comprehend how it

feels to be on the receiving end of care. Stories help people connect with care

experience and reflect on how it can be improved. Stories change attitudes towards

the role of local service users within the commissioning design process.

A common purpose and vision across the care system (within both commissioning and

provider organisations) creates a powerful force to overcome barriers to change; build

consensus across competing interests and organisations, and drive a transformational

focus on improving patient experience. This will ultimately improve the quality of care

and support delivery of the QIPP agenda.

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In fact, in terms of the seven factors identified as essential to patient centred care at

organisational level12

, ELC supports commissioners to deliver on all but two directly:

• Leadership at the level of the Chief Executive and Board

• A strategic vision clearly and constantly communicated

to every staff member

• Involvement of patients and families at multiple levels

• Supportive work environment for staff, which engages them in process design and

treats them with dignity and respect

• Systematic measurement and feedback

• Quality of the built environment

• Supportive technology facilitating information access for patients and

communication with their care givers

12 Shaller, D. (2007) Patient-centred care: what does it take? Oxford: Picker Institute and The Commonwealth Fund

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Next steps

We now plan to pilot the ELC programme in end of life care with a GP commissioning group.

Once we have identified the key interventions that help to change organisational thinking

and behaviour and have tested in practice the models that underpin our commissioning

management processes, we will be looking to expand beyond end of life care to other areas.

We are looking actively at: COPD, dementia and depression.

How you can help

We are looking to recruit more strategic partner organisations who share our vision of a

patient centred GP commissioning system. We are interested in talking to organisations that

can take forward our scoping work and move into a national roll out

To talk to us about our work, contact:

Georgina Craig, Managing Director

Georgina Craig Associates Limited

Best contact number: 07879 480005

Email: [email protected]

Louise Locock

Deputy Research Director

Health Experiences Research Group, University of Oxford

Research Fellow, Green Templeton College

Email: [email protected]

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Putting people at the centre of GP commissioning …...Page | 2 Putting people at the centre of GP commissioning: experience led commissioning “It is not often you hear about truly