Stephen Callaghan and Gina Perigo explain how using an outcome-based approach will help GPs to commission services based on quality, standards, and evidence

  • Commissioners need to understand and define what is meant by an outcome
  • GP commissioners can make a significant impact on improving individual and population health by using an outcome-based approach to commissioning
  • The 'ABC' model is the first outcome-based approach to commissioning that combines: the commissioning cycle, the required national competencies for commissioning, evaluation, and the principles of evidence-based care delivery
  • The key characteristics of the ABC model (see Box 1) were derived from the fundamental principles within the outcomes literature
  • Using process within a health-outcomes commissioning model is essential
  • The ABC commissioning for outcomes model incorporates both quality and process both of which will directly support the outcome
  • NICE commissioning support tools dovetail completely with the ABC model
  • The ABC model:
    • will support the future implementation of NICE quality standards and commissioning guides
    • can support future GP commissioners.

The content of the recently published White Paper, Equality and excellence: Liberating the NHS,1 and subsequent papers could not be more radical compared with the current approach to healthcare provision and commissioning.1 However, despite the growing concerns over implementation of the White Paper, the basic principle of moving towards an outcome-based approach to commissioning should be welcomed by healthcare professionals and commissioners alike.

Using an outcome-based approach, GP commissioners can make a significant impact on improving individual and population health and, in addition, achieve the five domains of the NHS Outcomes Framework.3 To be successful, commissioning should be on a large enough geographical scale and based on an understanding of what health outcomes are, and commissioners need to have a responsibility and accountability to ultimately achieve the best and most cost-efficient outcomes.

It is now widely accepted by various organisations and bodies1,4-10 that the way to understand and demonstrate the benefits of commissioning is to measure the outcomes of what we do and also those that are meaningful to people.2

The Nuffield Trust and King's Fund report in 2010 makes a case that if practice-based commissioners take responsibility for health outcomes they would also assume proper control of the service planning, development, and commissioning process.10 This assumption of 'proper control' should apply to any commissioning organisation. In order to commission for outcomes, commissioners need to understand and define what is meant by an outcome. The Health Outcomes Team at Liverpool Primary Care Trust (PCT) has defined an outcome measure as: 'A predicted measure of change that demonstrates a valid and significant therapeutic impact following an agreed intervention.'

Outcome-based approaches to commissioning

There are many outcome-based approaches to commissioning11-14 and each approach and measurement is often tailored to the individual needs of the organisation (i.e. local government). Despite the various different approaches, the New Economics Foundation highlights the need for a concerted effort to measure what is really important instead of vesting undue importance in what is easy to measure, and emphasises that it is a 'change of culture' that is required not just a new measurement mechanism.15

Any commissioning model in the NHS should reflect the commissioning cycle. If commissioning is based on outcomes, then not only should that model reflect the commissioning cycle but it should also contain the fundamental principles relating to outcome development within its structure. There is no 'one size fits all' model that is flexible enough to incorporate the variety of services that a large commissioning organisation demands.

ABC model

In response to the requirements of world-class commissioning (WCC) the Health Outcomes Team at Liverpool PCT developed an original outcome-based approach to commissioning: the 'ABC' commissioning for outcomes model. This arose because of a desire to improve the health of the population, improve and enhance commissioned services, and ultimately improve the quality and effectiveness of care to individuals.

The development of the ABC model was founded on a synthesis of the outcomes literature. It not only provides flexibility for the commissioner (in relation to the different types of service), but also incorporates quality, evidence-based practice, principles of evaluation, and competency. A supportive and educational environment to help 'change the culture' was then created to strengthen the strategic agenda of Liverpool PCT.

The 'ABC' model is believed to be the first outcome-based approach to commissioning that combines the commissioning cycle, the required national competencies for commissioning, evaluation, and the principles of evidence-based care delivery (see Figure 1, below). The ABC model can be used as the cornerstone for commissioning for outcomes. Furthermore, a core value of this model, and a marked benefit, is the manner in which it creates a cohesive way of matrix working by linking staff and directorates together to attain a streamlined approach to commissioning and the achievement of appropriate outcomes.2 The key characteristics of the ABC model (see Box 1, below) were derived from fundamental principles within the outcomes literature.

The ABC approach focuses on:

  • Assessment of need and delivery of the PCT strategic Aims
  • the use of the Best evidence to inform commissioning
  • the review of Current practice and a formal Critique of the evidence
  • the Development of meaningful and measurable outcomes
  • the Evaluation of services
  • ensuring that we Formulate the right data sets to assess the impact.

In practice, the commissioner follows the steps laid down in the model: the information gathered at one particular step, for example, B (evidence) is carried forward with the information obtained from step A (assessment of need) into step C (critique of evidence and review current practice) and so on.

Box 1: Key charecteristics of the ABC model
The ABC model:
  • is based on a synthesis of the outcomes literature
  • is generic (i.e. any type of service can be commissioned using the ABC model)
  • is flexible (i.e. one can start at 'E' if evaluating an existing service)
  • demonstrates transparency and clarity in decision making
  • supports pathway development
  • supports the Value for Money agenda
  • provides a structured and disciplined process for the commissioner
  • incorporates:
    • world-class commissioning competencies
    • evidence-based medicine/practice
    • NHS Evidence and other high-quality databases (e.g. Cochrane)
    • all NICE commissioning tools (including cost-saving guidance)
  • integrates:
    • quality and NICE quality standards and supports the wider quality agenda
    • policies, guidelines, and standards
    • the PCT prioritisation process
    • different outcome models (e.g. logic models, behaviour change)
    • evaluation
    • data sets.

Quality, process, and outcomes within the ABC model

There has been much debate as to whether the relationship between quality and health outcome is strong enough to be used to performance manage providers of care.16,17 Despite this Lezzoni concludes that, 'however imperfect, there is no other way to begin a productive dialogue with physicians and other clinicians about using outcomes to motivate quality improvement.17

Processes and outcomes
A key feature of quality improvement work is not only to understand processes, but to develop processes that will deliver on quality, efficiency, and satisfaction (e.g. adoption of Lean, Six Sigma approach). Using processes within a health-outcomes commissioning model is essential; for example, the 'process' of supporting patients to improve adherence to medication not only improves health outcomes but can also result in considerable savings.18 Furthermore, processes often improve outcomes in clinical trials even when the participant is taking placebo.19 Hence, the debate as to whether one should either use process measures or outcome measures to performance manage is over—commissioners should use both process measures (inputs and outputs) as well as outcomes measures.20

The ABC commissioning for outcomes model therefore incorporates quality and process, both of which will directly support the outcome (i.e. the outcome statement is built upon quality and process as well as an evidence base). Donabedian's 'structure, process, and outcome' approach to quality assessment21 is an internationally accepted concept that was incorporated into the well-recognised logic model22 used at step D of the ABC model (see Figure 1, below). We created a simpler logic model for commissioners in comparison with the one developed by the Kellogg's Foundation,22 without losing the fundamental principles and impact of the model. In order to implement the ABC model, the commissioner has to incorporate quality, process, and outcomes, which, as the literature suggests, delivers many benefits.

Benefits of the ABC model

The ABC model supports the commissioner in validating the need for a service, and provides a structure to describe and demonstrate the evidence, standards, guidance, quality, and efficiency through the use of this and our other models. The ABC model is also used to monitor and evaluate services to improve efficiency and productivity further. The integration of this model with the Value for Money framework has made the process of commissioning stronger within Liverpool PCT.23

The recent refinement of the National Institute for Health and Care Excellence (NICE) commissioning support tools dovetailed completely with the ABC model. Consequently, the model will support future implementation of the NICE quality standards and commissioning guides (currently under development) and the NHS Evidence database. In addition the combined ABC model and NICE commissioning guides will further support the GP commissioner to commission services based on quality, standards, and the most up-to-date high?quality evidence.

Benefits for the GP commissioner
The ABC model:
  • provides structure and discipline to implementing the commissioning process
  • provides evidence as to what the GP commissioner does, how it is done, and the methodology behind it
  • provides a clear and transparent approach to decision making
  • supports the prioritisation process
  • helps define, develop, implement, and monitor outcomes
  • supports the Quality, Innovation, Productivity, and Prevention (QIPP) agenda (e.g. outcomes in pathways)24
  • supports the GP commissioner to develop outcomes based on evidence
  • links key structures within the PCT (or any future commissioning organisation)
  • provides a formal approach to evaluation prior to procurement25
  • helps providers understand the commissioning process
  • stimulates continuous improvement (through evaluation)
  • demonstrates the use of the commissioning cycle.
Figure 1: The ABC model and the NICE commissioning support tools

Figure 1

WCC=world-class commissioning

Case study

Peer-to-peer breastfeeding support
In December 2010, Liverpool PCT commissioned a service for peer-to-peer breastfeeding support (an effective intervention to promote the initiation of breastfeeding).26,27 It is well recognised and advised that breastfeeding peer-support programmes should be commissioned only as part of a breastfeeding strategy and commissioners should be aware of all the recommendations on breastfeeding.27 A breastfeeding peer?support service was commissioned in line with other established services; it not only supports breastfeeding and infant mortality strategies, but clearly demonstrates how behaviour change is commissioned for within Liverpool PCT (see Figure 2, below).

The ABC model for the breastfeeding peer-support service is shown in Figure 3 (see below). For the purpose of this example, only the main headlines are shown as each step in the model contains a lot of background data (e.g. local assessment of need in step A—Liverpool PCT has not only data on the initiation rates as shown, but also statistics on age groups and areas [e.g. wards/neighbourhoods] in which poor breastfeeding rates occur).

Figure 2: Behaviour change model for breastfeeding

graph

Figure 3: Commissioning for outcomes—the ABC approach for breastfeeding

Figure 3

LPCT=Liverpool Primary Care Trust; WCC=world-class commissioning; PH11=Public Health Guidance 11; CG37=Clinical Guideline 37; BFI=Baby Friendly Initiative

Conclusion

We are 'changing the culture' of commissioners within Liverpool PCT and also PCTs across Cheshire and Merseyside through education and support. A consistent approach to commissioning for outcomes within Liverpool PCT can now be seen through the use of the ABC model and our supporting models. This investment in staff reflects what the New Economics Foundation highlights as essential—measure what is really important and change the culture.15 Further benefits have been realised by using outcomes and outcome models in other areas (i.e. care pathways) and by combining the NICE commissioning support tools.

Can the ABC commissioning for outcomes model support future GP commissioners to successfully commission for outcomes? This model has successfully supported a number of commissioners within Liverpool PCT and across the region. We believe that if services are commissioned within a structured and disciplined process (such as the ABC model) then it is irrelevant as to what the future commissioning landscape holds—the advantages of commissioning for outcomes and this particular model should remain the same. If GP commissioners focus on outcomes appropriately and understand that they should be measurable and significant enough to lead to a therapeutic impact then the answer to the above question 1is: 'Yes—the ABC commissioning for outcomes model can support future GP commissioners.'

Furthermore, by using the ABC model and selecting appropriate outcome measures, the positive impacts that can transpire for individual and population health will not only be realised, but positive long-term health gains will be achieved.

Acknowledgments

The authors would like to thank Kate McFadden for the use of the breastfeeding example.

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