Beginning with the end in mind: how outcomes-based commissioning can help unlock the potential of community services

This briefing from the NHS Confederation gives a concise outline of the practicalities of outcomes-based commissioning. This is an area which has received a fair bit of attention and whilst there have been a few reports advocating this approach, there has been surprisingly little in the way of detail. The briefing is based on the learning from a workshop of the Confederation’s Community Health Services Forum earlier this year and picks up on some of the practicalities involved in outcomes-based commissioning.

The impact of outcomes-based commissioning

The potential benefits have been covered fairly well in the literature to date; the briefing highlights a few including:

alignment of provider, commissioner and public goals
encouraging a more patient-centred approach
addressing the issue of perverse incentives
a focus on high-value interventions
prioritisation of prevention

But the challenges and risks haven’t always been outlined so clearly so I was encouraged to see that this briefing does acknowledge some of the barriers, including risks to sustainability, payment systems and securing investment.

The briefing gives a quick summary of joint venture contracting, alliance contracting and prime contracting.

As the Confederation acknowledges, there is a lack of robust evidence and independent evaluations of local implementations. Where outcomes-based contracts are in place, we’re starting to see some important lessons emerge. Three examples are included:

the Integrated Pathway Hub at Pennine MSK Partnership, a lead provider model responsible for all musculoskeletal services in Oldham (with a budget of £23 million) which is focused on health gain
the approach developed within Milton Keynes for captitated outcomes-based contracts, initially for substance abuse to manage fragmentation of services
the work now underway in Staffordshire to redesign cancer and end of life services, taking a long-term view and co-production approach to designing new pathways for 10-year contracts

Taking an outcomes-based approach

The briefing gives a concise overview of the processes involved in an outcomes-based approach, including the types of contracts and a few key critical success factors such as collaboration, engagement, governance and risk management. There are some useful tips for commissioners, such as the suggestion to focus on one outcomes-based contract at a time and to have realistic expectations about what can be achieved and by when.

Strong relationships are critical encouraging a collaborative and co-production approach to developing pathways and agreeing outcomes

The briefing is a good starting point for commissioners (and others) interested in taking this approach and there are examples which offer some insight on the processes involved. What’s needed now is to build the evidence base (through robust evaluations) and to facilitate knowledge and learning to be shared at a more granular level, across the health and social care domain.

Commentary

Commissioners will wish to consider:

what services may be appropriate for an outcomes-based approach? The briefing suggests it is a helpful approach for groups with poor outcomes; high-cost groups; and complex pathways.
what data is currently available or required to enable the measurement of outcomes?
what skills and capacity do commissioners have access to? What gaps exist and how will these be addressed?
what intelligence is available on local needs and priorities, from the perspectives of patients, public health, health and social care providers, charities, general public etc?
what needs to be done to strengthen stakeholder relationships to achieve a collaborative approach?
how can patients and the public be effectively involved (there is a growing body of literature on co-production)
how will risks around service redesign be managed effectively?