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Driving Change Through Commissioning

Delegates at the recent QIPP summit in London were able to study how one London PCT has used commissioning as a lever to drive quality and efficiency.

Driving Change through commissioning.


The Driving Change Through Commission breakout session was led by Laura Guest, Director of Strategic Commissioning and Deputy CEO of NHS Waltham Forest. Her organisation runs one of the first seven polyclinics to be set up in London and is at the forefront of polysystem development.


Adopting the polysystem model was part of a wider programme to drive quality and efficiency, with a strong emphasis on shifting care into the community and reducing inappropriate admissions. Waltham Forest has targeted a 40% shift to outpatients has been set over three years, with a corresponding 6-12% reduction in admission activity.


Health economics techniques have been used to drive efficiencies, for example by weeding out procedures of limited clinical effectiveness; and by providing patients most at risk of hospital admission with effective risk management, early intervention and enhanced community-based services.


A new commissioning framework


Driving this is a new commissioning infrastructure run by two partially elected boards: the polysystem development board and an entirely separate disinvestment group. The former is staffed by Clinical Directors, two Co-chairs, GP Board members from each practice, PCT Directors, lay members and commissioning specialists. The latter is made up of the Medical Director, lay members and the Executive Directors of the Trust.


Essentially, the development board, with its strong emphasis on clinical leadership, researches, develops and proposes services to be commissioned, whilst the disinvestment board exercises due diligence and final approval. This ensures there are no conflicts of interest, especially for GPs, whilst the elected dimension provides legitimacy in the public’s eyes, as difficult decisions are made.


The new polysystem


Laura Guest provided a detailed presentation on the new polysystem operating in Waltham Forest. This clinically led model of care involves GP practices, pharmacists and other independent contractors, secondary care clinicians and voluntary groups. Clinicians determine the shape of services locally and how they will operate to meet users’ needs: an excellent way of practice based commissioning at scale.


At the heart of the polysystem is a polyclinic ‘hub’. Opened last year, this provides an extended range of services from 8am until 8pm. These include GP services, gynaecology, sexual health, dermatology, cardiology, urology, physiotherapy, urology and diabetes care, under one roof and closer to home. Patient satisfaction ratings have been very high, in contrast to ratings for local acute trusts, which were in the bottom quartile.


This reveals an interesting aspect to commissioning. Says Laura Guest: “Research has found that few patients have been exercising choice under choose & book, so the assumption was the public wasn’t interested. This isn’t in fact the case. With the polyclinic people have been very much voting with their feet. We planned for 500 registered patients but have attracted over 3,000.”


As a result of the polyclinic’s success and following 17 service pilots, over £2m has been decommissioned in acute trust dermatology alone. In total 21 services have been moved into the community, delivering increased patient satisfaction and reduced costs: the perfect win-win situation.