Clinical engagement in high-value commissioning: elective surgical procedures

Importance of involving surgeons in the commissioning decision-making process

Rational commissioning

This report describes a project, led by Right Care, to involve surgeons in the commissioning decision-making process, because observations made by the Department of Health and Surgical Specialty Associations showed that there were inconsistencies in the rates of elective surgical procedures between Primary Care Trusts, and that sometimes existing surgical procedures were “classified as being of low clinical value”. It was felt that commissioning decisions made locally could increase variation in service delivery, and also cause conflict with secondary care clinicians, such as surgical staff.

The project had three objectives for the improved delivery of surgical services:

To reduce unexplained variations
To reduce geographical variation
To provide evidence based support to commissioners of elective surgical procedures

Strong partnership ensures engagement and ownership

Engagement

In order for these objectives to be met and to ensure engagement and ownership, key stakeholders formed a partnership, comprising representation from the Royal College of Surgeons England, the Surgical Specialty Associations, and the National Institute for Health and Clinical Excellence. To ensure consistency, a manual was written setting out the processes involved and by signing up to this manual, all members of the partnership have agreed to produce guidance which:

Provides evidence-based high-value care pathways on surgical intervention to commissioners
Highlights variations in service provision
Provides commissioners with measures to help them make commissioning decisions
Can be used by the local healthcare community to facilitate change
Links to good practice examples, and further information for patients and clinicians about high value care pathways
Highlights uncertainties, where there are gaps in knowledge, and makes recommendations for further research

Groups produced guidance for commissioners of surgical services

Commissioning guidance

Groups were set up to produce commissioning guidance on a set of surgical interventions for common conditions, such as tonsillectomy, knee pain, and low back pain, conditions that can cause long-term issues for patients and health care organisations. The conditions were selected using a set of criteria, including:

Burden of disease
Clinical priority
Clinical uncertainty
Resource impact on the NHS
Strategic importance

Each group had representation from commissioning, service delivery, and patient groups, and they did not just look at the surgical elements, but at the pathway as a whole.

This guidance produced as a result of this work, is supported by comprehensive literature reviews, and is meant to complement existing clinical guidance, and not to replace it. As a result of the consistent approach by which they have been developed, they have been formally accredited by NICE (National Institute for Health and Care Excellence).

Commentary

The report suggests that we ‘need to move away from a debate about “rationing” and instead have a debate about “rational commissioning”’. Rationing presents a negative image, one of reducing or taking something away from patients. Rational commissioning suggests that we factor in all stages of the care pathway, so that patients, primary, secondary and tertiary care, are all accounted for in the commissioning decision-making process. This should mean that patients will know what to expect and staff will know what to deliver, wherever they are based geographically and in whichever setting.

Having read this paper, how do you think your organisation could improve the transition between primary care and surgical care? Which of the commissioning guidance would be most useful to your area of specialty? Are there any that you think should also be on the list?