Commissioning considerations in delivery of care to all people with one or more LTC.

When commissioning services for people with LTC, Commissioners need to give equal consideration to a variety of service components, Diabetes Without Walls (PDF 1.8MB).

The role of commissioning is not just to improve services; it is to spend money wisely to get best value which includes the concept of high quality.

• The QIPP Right Care

The model below shows components of care and at the centre of this LTC model are the needs of the individual person with diabetes (and/or other long term conditions).The balance of these for each individual will depend on the nature of their condition, and the way the condition affects the person themselves. The three elements all commissioners will need to commission are:

• Traditional specialist care either as part of a surveillance and secondary prevention programme, or as part of clinical management.
• Collaborative one-to-one consultations between the person with diabetes and the healthcare professional, based on a partnership approach which is effective in supporting self-management. This is embodied in ‘care planning’.
• Services which support the individual living with the condition within their community with an emphasis on support for self-care.

Ten top tips for the commissioning of long term conditions

The DH Long Term Conditions Team has put together the following ten top tips for the commissioning of Long Term Conditions.
These principles also apply to the commissioning of diabetes services:

• Proactively create a user-centred, can-do culture. Create a simple user centred vision for the whole system, i.e. diabetes care, and promote it using clinical champions, user cases, etc.
• Share one vision, strategy, priorities and targets. Invest in a close working relationship with other commissioners focused on a single vision. Establish clear joint working arrangements and work as one team to develop a single joint strategy which meets the targets of all commissioners.
• Stimulate and support provider innovation to meet specifications. Encourage the integration of services that are not disease–specific e.g. community and social care. Support frontline co-working of integrated teams, e.g. team development, clinical champions, making populations coterminus. Facilitate exposure to ideas from elsewhere. Fund/use PCT capacity and capabilities to support projects.
• Assess user risk using existing algorithms with primary care data. Use a recognised method, e.g. the combined predictive model (Kings Fund) and clinical judgement or, failing that, a simpler method e.g. a whiteboard system.
• Innovate to educate and motivate users and carers for self care. Promote motivational interviewing and staff training. Also develop motivational counselling service for users. Promote on-going user education courses, e.g. QISMET – engage and incentivise GPs to refer; use sales and marketing techniques. Use expert service users.
• Specify few measures of outcome and experience, including integration. A single specification and contract for jointly commissioned services. Specify integrated care and only a few of the most pertinent metrics, e.g. delayed discharge, admissions avoided, user satisfaction.
• Clear professional responsibility for specific user outcomes. Assign responsibility for wellbeing of a defined population to a provider. Specify one ‘key worker’ for each service user to coordinate and integrate across services and professionals.
• Take quick wins and work-arounds in IT. Enable remote read-only access.Transfer paper records to one of the existing IT systems. Support development/ purchase of a new IT for a workable subset of providers.
• Establish information sharing protocols and consensus – Agree to sharing protocol between commissioning organisations. Ask providers to get user consent to share information with the other local professionals supporting them. Run pseudo-anonymised reports to share. Involve and engage clinicians; make information sharing optional for GPs initially. This can reduce duplicated care and testing.
• Engage and upskill primary and community care providers. Ensure GPs are engaged in all developments. Create or specify roles responsible for improving a defined skill-set in a defined provider set, e.g. GP practice staff ability to treat diabetes.