Report
Provisional Report of The Oldham Health Commission
Into Fairness in NHS Commissioning
1 - Background
In July 2010, the Department of Health published the white paper Equity and Excellence: Liberating the NHS. Amongst other things, this heralded plans to abolish Primary Care Trusts and hand over responsibility for most healthcare commissioning to new GP-led Consortia.
The Oldham GPs, as Commissioning for Oldham Group ('COG') began working up plans to develop into a GP Commissioning Consortium (GPCC) which, at the time of writing, are being advanced as a Pathfinder starting to take on responsibilities from the PCT.
To begin work to develop public involvement, COG devised an outline work programme and funding was secured from the Department of Health. The first piece of work arising from the plan was designed to begin to develop a public mandate - ensuring that GP Commissioners were seen to be acting fairly and with the support of the public.
This resulted in the creation of Health Commission, which was set up in the form of a time-limited Citizens’ Jury to run over four sessions from 4-20 April 2011. Oldham LINk came on-board to co-run the Commission and a reflective sample of 12 members of the public were recruited with an expert patient Chair, the sessions designed and suitable experts identified to act as expert witnesses.
The Chair’s comments below set out the context for the findings which are expressed a short, straightforward points in section 3.
Further details of the evidence and methodology can be found online at: http://www.oldhamhealthcommission.org.uk.
2 - Chair’s Remarks – Peter Bennett
‘Fairness’ is a very much used and abused term within political debate at present. Fairness really matters in the NHS.
Finite NHS budgets mean difficult choices have to be made. It is important to the public that the money the NHS spends on their behalf is allocated and spent fairly.
Defining the principles and practice of fair healthcare commissioning has proved a challenging task, perhaps more complex than any of us had anticipated. However, I am confident that having sat through considerable expert testimony, the members of the Commission have gained a real insight into the subject; and come up with recommendations which can contribute usefully to the framework for GP-led commissioning in Oldham.
From the outset, the process has been fair in the way that the methodology was put into practice.
This was before any of us were involved. It was carefully constructed to invite without prejudice a wide and broad a selection of people from the public who were not currently employed or known by Oldham LINk or NHS Oldham. The aim has been to achieve as great a level of impartiality as possible, bringing in fresh minds and perspectives. I believe that this has been achieved.
The whole group has fulfilled the conditions set out at the onset in participation and commitment, and I must congratulate them on the steadfast way in which they have all approached the whole of this project.
We found the speakers varied and instructive. They spoke to us, not at us, as well as imparting a massive amount of information. It was clear that this is a complex and difficult task which even the professionals do not take lightly.
Although the Group was recruited so as to be reflective of the Oldham population, we do not claim to represent the considered opinion of the population.
Our recommendations may raise some eyebrows amongst individuals and groups in the public sector and possibly the staff of the NHS. This is particularly the case around allocating a finite and fixed budget, thus prompting unpalatable choices.
However, I would encourage as many members of the public as possible to go onto the website http://www.oldhamhealthcommission.org.uk during the next six months to view the evidence for themselves and take part in the ongoing debate.
I am hopeful that with better education and understanding of the situation, we can endeavour to change the perspective that people have and in doing so be able to get an appreciation of the need to invest in prevention to improve health in the future as well as achieve a good quality health service in the present.
We trust that this report will be given careful consideration and I shall look forward to the response of Commissioning for Oldham Group.
Finally I would like to extend the thanks of the Commission members to Mark Drury and Rosie Kingham of NHS Oldham, Ursula Hussain and Jade Czuba of Oldham LINk and all of the expert witnesses who have given their time to assist the members of the Commission in making their recommendations.
Whether we agree with the national reforms or not, we know they will happen and we are determined to work with and support our GPs in Oldham to embrace the changes in a positive way.
Peter H. Bennett
Chair, Oldham Health Commission
20 April 2011
- THE FINDINGS -
3 - Basic Principles of Fairness
3.1 We affirm our belief in an NHS free at the point of delivery.
3.2 We accept that there is not enough money to give everybody everything they want, and choices have to be made.
3.3 We believe patients should be fully involved: both individually in making choices about treatment and collectively in commissioning decision making; at all stages and all levels including commissioner governance.
3.4 We do not accept the idea of deserving and non-deserving patients. However if, despite appropriate support offered, patients with capacity repeatedly choose not to follow clinical advice, we believe it is fair not to prioritise their treatment (NB There were 2 abstentions from supporting this view).
3.5 We support giving more NHS money to those electoral wards in Oldham with the worst health outcomes and less money to wards with the best health outcomes, to tackle health inequalities within the borough.
3.6 Although we acknowledge there will always be a need for treatment, we support gradually changing the balance of spending away from treatment towards prevention (including education on self-care, health promotion and using resources appropriately).
3.7 We support transparency in decision making and keeping the public informed about why decisions are made.
4 - Attributes of ‘fair’ commissioning for the NHS in Oldham
4.1 Identifying Needs
4.1.1 Make sure the need is understood, not just the demand.
4.1.2 Have a diverse mix of commissioners including a range of clinicians and non-clinicians.
4.1.3 Commissioners have to be objective and good listeners.
4.1.4 Understand underlying reasons for health inequalities and risky behaviours, and think beyond the ‘NHS offer’ to tackle health inequalities - housing, employment etc.
4.2 Making Choices
4.2.1 Adopt a consistent, transparent, published methodology for assessing the value of treatment and comparing the value of different treatments.
4.2.2 Prioritisation methodology should take into account:
4.2.2.1 Clinical effectiveness/ do-ability
4.2.2.2 Cost effectiveness
4.2.2.3 Impact on quality of life
4.2.2.4 Impact of quantity of life
4.2.3 Recommendations based on this methodology should be reviewed by a panel including lay members of the public as well as frontline NHS staff.
4.2.4 Clinical outcomes and patient outcomes are equally important, unless there is a cost implication, in which case clinical outcomes should take precedent over patient outcomes.
4.2.5 Recognise patient outcomes are subjective and individual.
4.3 Service Design
4.3.1 Services should be designed around those who need them most and be accessible to all.
4.3.2 There should be a consistent standard of, and access to treatment.
4.4 Contracting
4.4.1 We support treatment by any qualified provider, but competing primarily on quality rather than cost alone (NHS or private) and not endangering the viability of any local District General Hospital.
4.4.2 Contracting should be a transparent process without scope for potential conflict of interest.
4.5 Evaluation
4.5.1 Insist on high quality real-time patient experience data from providers.
4.5.2 Identify and act upon all the opportunities in the patient pathway to capture patient feedback and feed this into the commissioning process.
4.5.3 Gathering patient experience data should be part of the 'day job' for clinicians.
4.5.4 Use robust evidence of patient outcomes - measure success over the long term.
4.5.5 Provide patients with multiple, easy ways to feed back on their experience.
4.5.6 Providers and contracts should be assessed on their component parts rather than as a whole.
You can download the report here.
The formal response to the report can be found here.
Before commenting on the report, we would strongly encourage you to take the time to go through the supporting evidence here.