UNIVERSITY OF BEDFORDSHIRE
AssignmentTutorOnline
FACULTY OF HEALTH AND SOCIAL SCIENCES
MSc. PUBLIC HEALTH
HEALTHCARE COMMISSIONING
PUB012-6
CRITICAL APPRAISAL
BY
——-
JUNE 2014
Table of contents
Introduction……………………………………………………………………………………………..3
Background…………………………………………………………………………………………….3-4
Critical Appraisal 1…………………………………………………………………………………..5
Strengths………………………………………………………………………………………………..5-7
Weakness……………………………………………………………………………………………….7-8
Critical Appraisal 2……………………………………………………………………………………8-9
Strengths………………………………………………………………………………………………..9
Weakness………………………………………………………………………………………………10-11
Conclusion……………………………………………………………………………………………..11
References……………………………………………………………………………………………..12-14
INTRODUCTION
This paper aims to critically appraise two healthcare commissioning scenarios, which were presented in the form of posters that were hypothetically done in Nigeria and Kenya. It will systematically explore the appropriate commissioning theories discussed in each poster and its application as well as highlighting their strengths and weaknesses.
A review of relevant literature to support the analysis will be done, making reference to the Royal College of General Practitioners (RCGP) (2011) and World Class Commissioning (2007) framework as important guidelines in commissioning. Finally, this paper will conclude by evaluating the key findings discovered in each healthcare commissioning scenarios and how they can be applied in producing an effective and evidence-based healthcare practices in the future.
BACKGROUND
The transition from the biomedical definition of health as just being the “absence of disease” to a more inclusive and holistic approach of being a “complete state of physical, mental, and social well-being” has expanded the scope of health (World Health Organization (WHO), 2006, p.1). This clearly indicates that there are a whole lot of factors influencing the health of an individual other than disease. The social model of health by Dahlgren and Whitehead (1991) support this by identifying a wide range of determinants of health such as lifestyle, genetic predisposition, unemployment, housing, social and community networks, and environmental and socioeconomic factors. There are four significant elements that determine an effective health system which are: accessibility, availability, acceptability and quality (WHO, 2007). This simply means that public health and health facilities should be functional: non-discriminatory, easily accessible, sound medically and gender sensitive thereby reducing health inequalities. On this note, the Department of Health (DoH)(2007) defined healthcare commissioning as the process of interpreting health and wellbeing needs and demands into services through specifications and procurement of services that improve health equality, produce effective health outcomes and making use of the best available resources for better achievements. Similarly, healthcare commissioning is the systematic approach that encompasses assessing the health needs of the local population, identifying and prioritising the health needs, procuring services to accomplish proposed outcomes, and providing support to services providers ensuring that the outcomes are delivered effectively for service users.
In England, according to a report by the House of Commons (2010), the framework of commissioning has been undergoing changes since the initiation of the National Health Service (NHS) in 1948. It started in the 90`s, where it was formerly under the charge of the District Health Authorities [DHA] in which commissioning was focused on just spending on health services (Great Britain, Health Committee, 2010), to Clinical Commissioning Groups (CCG`s) whose responsibility is to promote social and health outcomes of the community through acquiring relevant heath services in line with the needs of the community (RCGP, 2011). Moreover, with the clinically-led commissioning being introduced, healthcare commissioning has shifted from the Primary Care Trust`s (PCT`s) commissioning model that was accused of being too expensive to run and was also focusing more on management issues rather than prioritising the needs of the local community (Great Britain, DoH, 2010). Although, with the involvement of the clinicians in the process of planning and providing of healthcare services locally, healthcare commissioning will enhance the population`s quality of life prioritising their health needs (NHS Confederation, 2011). However, healthcare system can be complex and very expensive as it requires the commissioners to get on board a wide range of disciplines in order to deliver an effective outcome (Ham, 2008).
In 2007, the World Class Commissioning framework was introduced to provide guidelines for commissioners to be effective and proactive. It has 3 central constituents; critical planning, acquiring services and monitoring/evaluation. This framework provides 11 administrative competencies that set out skills, knowledge, behaviors and characteristics needed by commissioners to deliver a world class commissioning standard. These competencies should be transformed into excellence thereby making sure the wellbeing as well as the health outcomes of the population is the primary focus (Great Britain, DoH, 2007). Additionally, it is the responsibility of the commissioners to reduce health inequalities and primarily improve health. However, this can be difficult to achieve within a specific budget, therefore, prioritising funding towards areas with wider health inequality is of utmost importance (RCGP, 2011).
This paper will examine an critically appraise these posters based on RCGP and WCC frameworks
Poster 1: Healthcare Commissioning Service in Nigeria
The context for the commissioning scenario was hypothetically about healthcare services in 8 districts of the Federal Capital Territory (FCT) of Nigeria. The commissioning team were members of the advisory committee on health in the FCT council. Following this manner, town hall meetings were held with religious leaders, parents, GPs, mental health specialists, and civil groups and it was gathered that the causes of suicide amongst young people were substance abuse, psychiatric disorders, violence, among others. The team later initiated the commissioning process by setting up a consortia involving parents, GPs, health educators, religious leaders, school counselors, mental health specialists, social workers, media and civil groups. The aims of the consortia were to reduce suicide related morbidity and mortality by 50% in 1 year as well as increase general public awareness about suicide. Furthermore, the budget was made and the impact of the intervention was validated using the mortality and morbidity rates as indicators.
Strengths
The poster lays out the context and rationale to support the necessity for commissioning. This is vital, as healthcare commissioning should be based on the needs of the community relieving them of distress (RCGP, 2011). Similarly, both the context and rationale provide a platform that determines if healthcare pathway is important for the community, patient and finance disbursement.
Additionally, this poster identifies that due to the high rate of suicide amongst young people (ages 16-29), they decided to conduct a health needs assessment on the community. A report by NICE (2005) clearly explains importance of this phase in healthcare commissioning as it gives a broad understanding and knowledge of the needs of the community which helps the commissioner in strategising and prioritising these needs in order to advert preventable inequalities and improve the community`s health outcomes within a restricted budget. This is also supported by WHO (2001) in its definition of health needs assessment that states that it is a systematic approach of appraising and analysing the health needs of the community thereby prioritising and prudently allocating resources. Also, HNA gives the commissioner an opportunity to work with the community in improving their health outcomes. Likewise, according to one of the principles of healthcare commissioning by the RCGP framework (2001) highlights the importance of health commissioning to be community -led by engaging and empowering them in prioritising their health needs and also designing healthcare services. This will help not only in identifying and prioritising the needs but also making the healthcare system effective in addressing the health needs of the community (NICE, 2005).
A consortium being set up is another crucial part of the healthcare commissioning process. The poster mentioned that the team set up a consortium after conducting a health needs assessment. This is in agreement with the RCGP Framework (2011) which indicates the significance of commissioning to have a collaborative effort that involves a multi-disciplinary approach. Moreover, this framework further explains the importance for commissioners to be able to work with other local and international stakeholders to create integrated healthcare systems that are cost-effective. Similarly, Crump and Mavro (2011) argues in their User led Organisations (ULO) Consortium Toolkit the need for a consortium to consist of organisations that have same goal that meets the health needs of the local community. They further explain that individual organsations should focus more on cooperation rather than competition and also have a clear vision all through the healthcare commissioning process. In line with this, the team of commissioners collaborated with other local stakeholders of the consortium to arrange the procurement of a subsidized healthcare services, however, not specified.
The poster also showed another important aspect of healthcare commissioning which is community engagement. They did this by having meetings with local community leaders, religious leaders and other key members of the community. This is supported by the DoH (2007) that highlights the need for healthcare commissioning to be community oriented which means that commissioners should endeavor to engage with the community all through the commissioning process. Thus, encouraging the community to take control of their health and wellbeing.
Although, this poster has identified some important features in the healthcare commissioning process as mentioned above, however, a good number of significant aspects was not clearly justified and also key principles as outlined in the World Class Commissioning Competencies required for commissioners to be effective were omitted. The poster weaknesses are therefore mentioned below;
Weaknesses
The poster fails to illustrate systematically, how the team of commissioners conducted the health needs assessment. The poster mentioned that a hospital- based mortality surveillance in the 8 districts of the FCT revealed an increase in non-fatal suicides amongst young people before the team set out to conduct the health needs assessment. However, the commissioners failed to explicitly mentioned where the information came from before they went for the hospital surveillance. This could possibly lead to misplacing the health needs of the community and a wrong approach in assessment. RCGP (2011) asserts that the basis for healthcare commissioning must be evidence-based.
Although the team set out to commission a service, there are so many ambiguous statements in the poster that does not state the specific details of the intervention to be commissioned. This could therefore result in the procurement of a service that does not meet the needs of the local community, difficulties in introducing a new service, and an unclear review and evaluation. The proposed intervention is not sustainable. Since they identified suicide as the issue in the local community, the team should have worked towards commissioning a service to reduce the rate of the associated suicide mortality rather than seeking ways to improve the rate of detection, primary, secondary and tertiary treatment as mentioned in the poster. In support of this, RCGP (2011) affirms that developing a sustainable and cost-effective healthcare system is an important aspect of commissioning. Furthermore, the World Class Commissioning Framework (2007) states that commissioners must be able to come up with investments that add quality and improve the health outcomes of the local community in a long term. In view of this, the team of commissioners should also bear in mind that coming up with a long term solution to the problem will help the districts of the FCT that had no suicide related cases.
The poster does not mention that the consortia was comprised of any recognized local or international stakeholder. Moreover, the responsibilities, and vision for the for the execution of the service to be commissioned by members of the consortia was not clearly highlighted. The World Class Commissioning Framework (2007), states that commissioners should set out their goals and be unambiguous on their objectives, skillful, visionary leaders and confident in their function. In regard to this, a conclusion can be drawn that the commissioners underestimated the significance of a consortia. According to the World Class Commissioning Framework (2007),key competence (2), a consortia is vital in healthcare commissioning because it gives avenue to share skills and knowledge thereby promoting new innovations that will better the health outcomes of the community. The poster mentioned that the commissioners where allocated a budget of $100,000 for the procurement of service for the first year of the commissioning process but they never presented in details how the fund was made available and for what services it was meant to procure.
Lastly, the poster showed that the team used a competitive procurement process but made no justification to why it was the preferred. Commissioners can only choose to go for a competitive procurement process when there is a complex procurement that they cannot provide the financial framework and technical prerequisites of the project (Great Britain. Office of Government Commerce, 2008). Furthermore, declaring an interest in competitive procurement process normally needs a 37 day time frame in addition to 12 months from the publication of notice to the final deal signature (Great Britain. Office of Government Commerce, 2008). However, the poster has not mentioned the time frame for procurement of the service, and this is not a characteristic of a competitive dialogue procurement process.
Poster 2: Healthcare Commissioning Service in Kenya
The context for the commissioning scenario was hypothetically about a healthcare service to control jigger in Kenya. The commissioning group were members of the Ministry of Health in Kenya. The poster in-cooperates the RCGP and CCG Frameworks within the commissioning process. Sources of information available to the group included: schools, churches, local clinicians, local chiefs and previous studies carried out. Health needs assessment is carried out using the Joint Strategic Needs Assessment in line with the RCGP and CCG guidelines. Literature review on the issue was done on previous studies to back up the findings from the assessment. The group highlighted their objectives to be a preventative program which will include; education on jiggers, sanitation and identifying risks, to supply shoes to reduce infestation, dig boreholes, fumigation to kill and case surveillance.
The group advertised in the local press for interested vendors to tender bids for the procurement of service with key requirements in knowledge of jigger, competitive price, knowledge of the local dialect and previous experience of running similar program. The service will be monitored by the group every 6 months to evaluate the outcome. Progress meetings with the local community, clinicians, schools, parents, and churches will be held as part of monitoring and evaluation.
Strengths
The poster describes the healthcare commissioning process in a clear and succinct way using the RCGP (2010) competency all through the scenario.
The group set out objectives and arrived at a framework of how the issue of jiggers in Kenya will be curbed. In regards to this, (NHS, 2011), in its model of healthcare leadership asserts that a commissioner acting on the capacity of a leader must be capable of designing a plan of action that will reduce health inequalities and better the health outcome of the local community. Furthermore, the RCGP commissioning framework (2011) states that services which aim to better the health outcome of the local community must be designed by the commissioners. The poster highlighted that the group conducted a health needs assessment in line with the RCGP commissioning principle. Finally, the group highlighted the parameters that will be employed to evaluate and monitor the service. Evaluation and monitoring is a vital aspect in healthcare commissioning as stated in the RCGP commissioning framework (2011) which states that commissioners should monitor the quality and the performance level of services. Furthermore, it will give details on the service that has not met the proposed target, give information on ways to offer improvements, and the service that needs to be decommissioned.
Although, this poster identified some vital features in the healthcare commissioning process as highlighted above, however, some relevant aspects were not clearly outlined and key principles of the World Class Commissioning Competencies required for effective commissioning were omitted. The weaknesses are therefore mentioned below;
Weakness
The commissioning group proposed to commission an intervention across Kenya as a whole. This is a practically impossible step as it will take more years than anticipated as a result of the resources to be put in place and the process for the service to be accomplished. This means that the group will have to consult and engage with all the churches, schools, local authorities and members of parliament in Kenya. Therefore, it will be a very painstaking and time consuming task to execute. The group would have been better off starting with some districts to evaluate their plan of action and measure the effectiveness of service.
The poster failed to highlight the context and rationale to support why the service was a necessity for commissioning. This opens up some many unanswered questions: Was the intended service for the young or old? Why did the commissioners decide to commission the service? What informed the health needs assessment? These questions needs to be clarified to ensure the essence of the service.
The group failed to demonstrate systematically, how the health needs assessment was conducted. They only stated that they focused on poverty prone areas with characteristics of muddy houses and shared housing with animals before the group went ahead to conduct a health needs assessment. In addition, health needs assessment should be conducted in a systematic way that engages and assesses the needs of the local population in an attempt to provide the needed healthcare service that will be designed (NICE, 2005). However, the group did not follow this process but rather used irrelevant information to depict the health needs of the local population. In this regard, the group did not work with the guideline of the RCGP (2011) which states that the healthcare commissioning must be evidence-based.
The poster does not mention that a consortia was set up or any collaboration made with a local or internationally recognised stakeholder. Setting up a consortia to work in partnership with the commissioners during the commissioning process is important as it will ensure effective service delivery and reduce avoidable barriers. This shows that the commissioners took lightly the importance of a consortia in their process of service commissioning. Another weakness highlighted in the poster is seen in the budget session. The poster mentions that a budget of £480,000 for the procurement of service was made available to the commissioners but it does not state explicitly which organisation or government body made the funds available for the commissioning process and what services it was meant to procure.
Finally, the poster did not mention procurement throughout the commissioning scenario. The procurement stage in the commissioning process starts with a detailed outline of the intended service to be provided and specifications to meet the needs of the local population. Although advertisement was made in the local press for interested candidates to tender their bids for the procurement of services, the commissioning scenario failed to mention the need for unsuccessful candidates to be communicated to. According to the RCGP (2011), commissioners should employ an open and transparent procedure that foster positive partnership in the process of commissioning. However, the group of commissioners failed to make the bidding process open and transparent. Furthermore, the medium for advertisement that would be used like the television, newspapers or radio was not mentioned although the poster highlighted that local press will be used. The RCGP Framework (2010) states that in the process of commissioning, communication plays a important part in strengthening the relationship between the commissioners and the general public.
Conclusion
The two (2) posters illustrated different methods of commissioning a healthcare service in their respective communities. The commissioning scenarios identified the key competencies and guidelines set by the World Class Commissioning and the Royal College of General Practitioners Framework highlighting both the strength and weakness of the posters. Both posters tried to adapt the ten (10) commissioning principles throughout the scenario though the strengths and weaknesses would have been avoided with the in depth knowledge of the guidelines and policies for a service to be commissioned.
In conclusion, it was necessary to critically appraise these posters to develop a better knowledge of the key competency and theoretical characteristic of commissioning .
REFERENCE
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