How to improve patients' health through commissioning

Commissioners are responsible for improving the health of their populations as a whole. They are also responsible for commissioning high quality health services for patients, and for remaining within their financial budgets. The extent to which these three priorities compete will depend upon the local financial position.

There are two main approaches to improving health:

1. At the 'population' level, through health promotion, prevention, and tackling the socioeconomic determinants of ill health in collaboration with local government and others
2. At the health care level, through commissioning to improve clinical outcomes for patients.

The focus of this article is on the second approach.

Who identifies the priorities?

Not all measures designed to improve patients' health necessarily require financial investment. However, it is fair to state that those brought to the attention of commissioners almost invariably do. Investment bids are considered towards the end of the financial year, as part of the process of development of the local development plan (LDP).

It is not usually difficult to identify a long list of potential priorities for investment, most of which will be legitimate in terms of improving health. The difficult part will be in deciding between them, particularly if there is little or no new money for investment. In these circumstances it may be necessary to make cuts in other services in order to pay for new developments, so commissioners will need to be very confident of the net benefits to patients' health.

Priorities for investment come from a number of different sources:

• Department of Health targets and 'must-dos'
• NICE guidance and guidelines
• Demand from local clinicians, patient groups and individual patients
• Demand from politicians and the media
• Evolving clinical practice, leading to cost pressures and service developments in provider organisations (eg, new drugs and technologies, emerging evidence).

In practice, targets and 'must-dos' are usually unavoidable and will normally be put at the top of the list.

The distinction between a cost pressure and a service development is blurred. The term 'service development' is usually reserved for major changes in service provision, as opposed to incremental changes in clinical practice and the costs of care. Under payment by results (PbR), ¹ providers will in future be expected to manage cost pressures within the tariff price. (The tariff price of a procedure or episode of care is the standard price set by the Department of Health, based on national average costs. All elements of care, including supporting service costs, are included within the tariff unless explicitly excluded.) However, commissioners will still need to decide whether they will commission new therapies which are currently excluded from the PbR system.

Assessing the priorities

Let us assume that after allowing for 'must-dos' there is still funding available for other priorities. Commissioners will need to develop a transparent, defensible and fair process for weighing up alternative options for investment. The criteria in Box 1 have been used to assess specialised service developments in the Central South Coast Specialist Commissioning Consortium, which commissions specialised services on behalf of the local primary care organisations.

Investment proposals which meet all or most of these criteria are the most likely to obtain funding. The extent to which each proposal meets the criteria can be assessed using a scoring system such as that in Figure 1.

An important criticism of the scoring system approach is that it attributes a spurious scientific validity to what is essentially a subjective process. However, attempting to decide between priorities without a clear process will expose commissioners to challenge.

Because of the subjective and value laden nature of priority setting, local commissioning organisations in many parts of the country have collaborated to set up clinical priorities forums. This is to ensure that the process is fair, transparent, and based as far as possible upon a consensus decision.

Comparing cost effectiveness

Even the National Institute for Health and Clinical Excellence (NICE), with all the expertise and resources at its disposal, makes recommendations that attract controversy and criticism. Commissioners have to make decisions based on much lower standards of evidence. Public health consultants and specialists are trained to identify and assess evidence from the published literature. However, demonstrating that a therapy or service is effective in terms of improving patients health is not enough; commissioners also need to know how cost-effective it is, compared with competing priorities. In other words, what is the cost per unit of health benefit?

Quality adjusted life years (QALYs) are a useful tool, but the cost per QALY of a particular therapy is only as robust as the assumptions that have been used in its derivation. In practice, few commissioning organisations have the resources or expertise to assess cost effectiveness in terms of QALYs. This means that commissioners have to weigh up the relative health benefits and associated costs of competing investment priorities empirically.

The cost of any therapy is its opportunity cost. Opportunity cost is the health benefit forgone by not putting the resources to an alternative use. This is an important principle because by funding a particular therapy we are depriving other patients of health benefit.

Table 1 shows the opportunity costs of some common elective procedures. ² For example, the opportunity cost of one haematological stem cell transplant is equivalent to about 11 coronary artery bypass procedures. This means that the health improvement derived from a transplant has to be at least 11 times greater than that from a bypass to be of equal cost effectiveness.

Conclusion

When resources are limited, commissioning to improve patients' health requires commissioners to decide between competing priorities for investment. Whatever process is used to prioritise, it must be transparent and above all fair. Setting priorities should not be left to individuals but should be a formal process, supported by public health advice.

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