Quality

This chapter looks at the topic of health services quality from a commissioning and whole population perspective. Quality is noted to be a multidimensional concept and dimensions of quality are considered. The role of the commissioner in maintaining and improving quality of services is explored, and this is seen within a wider backdrop of a health system with commissioner and provider functions (if there are such distinctions in the system). Commissioners need to know whether they are securing quality care for their population for the money spent. They also need an understanding of how this dovetails with the provider perspective on this topic. Commissioners also need to be able to articulate what they wish to assess in practice under the guise of quality. Finally, at a system level there are also bearings on how to compile and interpret a picture of a population’s health if needed.

Recognizing Whether You Are in Simple, Complicated, or Complex Problem Territory

This chapter is a succinct stop for orientation to the concept of complex situations, as the latter are an inherent part of working in health systems. Knowing whether you are in a simple or a complex problem territory and adjusting your approach accordingly is important for decision-makers. The important thing is to be able to recognize these situations. Drawing from the classic literature on the topic, the main features of simple, complicated, and complex situations are described. It is acknowledged that commissioners in health services are often dealing with, or contributing to dealing with complex situations. Addressing this complexity will need to draw on the different perspectives, skills, and experiences that may come from many disciplines and there are often no quick solutions as such. Some practical tips are offered.

Evidence Hierarchy

This chapter is about making sense of evidence from research studies from a commissioner and evidence-user perspective. A basic evidence hierarchy is described for general orientation to the concept that some study designs are more reliable than others in attempting to understand cause and effect, and there is orientation to the main study types in the hierarchy (randomized trials, cohort and case-control studies, etc.) Clearly it is the overall weight of evidence for a particular course of action that is important, although familiarity with basic concepts of study robustness remains useful in itself for making sense of the many items of evidence that present in everyday practice. The value of evidence from studies addressing non cause and effect type questions (for example seeking understanding about behaviours and beliefs) is discussed. The role of the evidence-user in making use of these concepts and enabling evidence informed practice is also described.

Commissioning Needs a Population Perspective

This chapter looks at the synergistic relationship between the concepts of commissioning and population health gain, and some practical ways to enable this connectivity. In simple terms, commissioning refers to securing services for the population, and a whole population perspective is clearly integral to this effort. This chapter introduces four key perspectives of a population approach that can be applied to any health issue in the commissioning sphere. These are the consideration of Epidemiological context, effective Preventive opportunities, a focus on addressing Inequities in access and outcomes of care, and a whole Care pathway and System perspective. (The acronym ‘EPICS’ can be used to aid recall if needed). Application of these would be underpinned by using an evidence-based approach. Together these summary perspectives offer a quick schema to scope any health topic in practice which can be used as needed for the task in-hand. Examples are given.

Purposeful Use of Health Intelligence

This chapter considers how commissioners can frame the questions they pose of health information sources, so that they gain more meaningful answers to help commission for health gain. There is an overview of the three main purposes for using health information from a commissioning perspective. These are namely to help problem definition, plan and prioritize, or to monitor and evaluate actions taken. There then follows further practical guidance to assist fuller appreciation of the health information territory. This includes general themes covered by health information, example sources, and a salient reminder that whilst health information is important for commissioning, it is only one type of tangible knowledge that the commissioner needs for decision-making. Other salient knowledge that a commissioner needs for sense-making is also noted (a ‘Trio’ of knowledge is needed for commissioning). Finally there is also an orientation on making sense of economic evaluation information from a commissioning perspective.

Introduction

This introductory chapter sets out the book’s practical purpose to be a useful and salient guide in the real life arena of commissioning and health services decision-making for better population health outcomes. The book is grounded in the experience of health services in England where the intention is to provide a comprehensive range of services on a whole population basis. The reader will be taken through the book using the main anchoring point of commissioning, the process of securing services for populations within finite resources. The book is structured in two parts. The first half (Part I) contains core topics to help build confidence about commissioning for health gain. It covers the purpose of commissioning, its health service context, and offers concepts that tangibly link commissioning actions with a population approach. Part II builds on that to cover more applied topics that commissioners will need to navigate in practice.

Taking Stock for the Future

This is the final chapter of the book. It is a preparation for the reader’s onward journey. It includes a summary of the main things to keep in mind throughout practice and how to dip in and out of the chapters as needed. Beyond the nuts and bolts there is a reminder that it is also important to reach a transformational stage in commissioning for health gain rather than just the transactional processes. The theme of building capacity and enabling a system that nurtures a population approach to health services decision-making is discussed and the contributions of education and research to this theme are recognized. The ‘evolutionary’ nature of health services is acknowledged and transparent processes for population approach remain salient whatever the structures of the day.

Spectrum of Effective Preventive Opportunities

This chapter provides a means of looking at a health condition or health issue through the lens of identifying effective preventive opportunities. The concept of an effective preventive opportunity is firstly clarified for use. A ‘spectrum of preventive opportunities’ model is then described which can be used to identify these opportunities for any health condition. In this model, effective opportunities are considered across a whole generic care-pathway chronology, which also acts as a prompt to considering the potential range of health service responses and to help think about the natural development of the health condition or issue. Examples illustrate that the principles can be applied to single conditions, groups of conditions, and system issues. There is also a ‘population health sieve’ summary of the different risk factor types in a population, and a summary of the different types of health service response.

What Can a Commissioner Do About Health Inequalities?

This chapter looks at the role of a health services commissioning function (or equivalent planning function) in addressing health inequalities of access and outcomes of services. Working definitions of health inequalities and health inequities are described for use. The backdrop to health inequities in populations is also described for orientation. The chapter then considers the roles of commissioning in contributing to reducing such inequities of access and outcomes. Commissioners’ generic responsibilities, direct contributions, and collaborative roles are captured. It is further noted that taking such a whole-system approach and recognizing the value of ‘starting early’ is also very apt for commissioners, as achieving equity of service outcomes depends not only on equitable access to services, but also to some extent on reducing the differentials in early risk factors in a population, as the latter can impact later outcomes even with seemingly equitable access to treatment services.

Public Health

This chapter is about the terminology and practice of the public health specialty to assist insight into its connections with health services for populations. Public health practice is about considering health at a population level. For orientation, the semantics of the term public health are also discussed as part of aiming for effectiveness of dialogue in this area of health service practice. In the public health specialty there are three core domains of public health practice, and healthcare systems will interact with all three. One of these domains, Healthcare Public Health (HCPH) is particularly relevant to the commissioning of health services. This is concerned with improving health outcomes through health services quality and effectiveness. Its work is an integral part of the commissioning function for health services. All three domains are described for the commissioner’s orientation, namely the work of health improvement, health protection, and healthcare public health.