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JUNE, 2014
This essay will critically evaluate two hypothetical healthcare commissioning scenarios, with a view to pointing out the strengths and weaknesses of the commissioning processes.
Each commissioning scenario will be concisely summarised for a quick insight into the commissioning context and rationale. This will be followed by pointing out what was done right and those not done well, basing the judgement on both the Royal College of General Practitioners (RCGP, 2010) and World Class Commissioning (WCC – DoH, 2007) frameworks.
Thereafter, conclusions will be made at the end with a suggestion of how the interventions could be practically applied.
As a guide, a brief introduction to healthcare commissioning will help in laying the foundation for the appraisal. Gillam & Siriwardena (2013) described healthcare commissioning as a process by which commissioners plan and provide healthcare services to meet the needs of the population for whose health they are responsible. However, it is not usually enough to just provide this services, the interests and opinions of the service users normally play key roles in decision making and planning (Lawrence, 2013). Hence, consultation with service users ranks top on the list of commissioning principles. Through consultation, health needs and inequalities can be assessed, and priorities are determined and accorded due attention (Atkinson et al., 2013 and DoH, 2006).
This is then followed by a systematic procurement process including competitive contracting for necessary service provision (Glasby, 2012). To ensure effectiveness, monitoring and review of service delivery are usually carried out periodically. This may lead to improving quality of service or decommissioning existing ineffective services as the case may be. Meanwhile, according to Learmonth (2003), success is easily achieved in the commissioning process when a broad range of people with different professional background work in partnership to form a commissioning consortium under appropriate management systems and leadership. The consortium may include commissioners, healthcare planners, policy makers, fund holders, service providers, recipients and researchers who provide evidence for effective practice. Commissioners are usually expected to effectively utilise the resources provided by fund holders, the government through the NHS in the case of UK, for instance, under a workable budget, in procuring appropriate and need-based priority-driven health services from the providers (DoH, 2006). They are also expected to have a set of commissioning competencies; skills, knowledge and attitude that would enable them work effectively and achieve desirable and measurable results (Morgan-Jones & Wilkie, 2013 and Gupta, 2011). However, management of people in partnership through leadership is often characterized by unpalatable challenges, especially when opinions are varied and interests are conflicting (Elston, 2013). This normally requires the team resolving their differences using appropriate conflict resolution models like the Five-Step Appeal and LEAD Models (Puthussary, 2014). Health equity audit, sustainability and community engagement are also key factors in healthcare commissioning.
Having reviewed key concepts in healthcare commissioning, the stage is now set to critically evaluate ers in terms of case context, rationale of the commissioning, commissioning competencies, framework and principles, method and extent of application of the principles, conflict resolution models, commissioning processes such as planning and partnership, procurement strategy including the type and rationale of the procurement method, services needed to be procured, source of funding, as well as the monitoring and evaluation method applied during the commissioning exercise.
In this scenario, the ‘commissioners’ are members of the commissioning group, Ministry of health, Kenya, who aim to control Jigger in Kenya. To inform their decision and to aid in assessing health needs, information were gathered from different sources such as schools, churches, etc. The result of the assessment helped in identifying issues surrounding the health condition among which include poor sanitation, lack of sensitization, poverty and stigmatization.
Having assessed and identified the needs, approaches towards controlling the condition were outlined to include jigger prevention awareness, provision of shoes and boreholes, fumigation and case surveillance. This prevention programme is intended to run for a period of three years and would require the services of experienced and qualified individuals who have knowledge of what is intended to be done and can help with proper community integration especially with respect to language barrier.
The programme is to be implemented within a budget of £480,000 equivalent. The contract for procurement services were awarded to individuals who met the bidding criteria. There is also a plan to monitor and evaluate the progress and effectiveness of the programme.
Healthcare commissioning is usually carried out by a group of people known as commissioners with the mandate of being responsible for the health of a group of people in a defined geographical location. It is obvious that the presenters have clearly identified themselves as members of the commissioning group, Ministry of Health, Kenya. This identification would probably eliminate the barrier of being perceived as strangers and the consequent withdrawal effects. It could rather aid acceptability, encourage active participation by community members and enhance public engagement which might eventually lead to programme sustainability and success in some ways.
Also, the presenters have systematically reviewed the health needs of children under school age, having gathered information from their lived experiences through qualitative interviews, dialogue with church and school heads as well as existing literature, and identified their major challenges. This is in line with the views of Wright and Cave (2013), who also believe that health need assessment should systematically identify unmet needs with a view to providing appropriate solutions, setting priorities and helping in policy development. Health needs assessment is fundamentally important in service design, improving quality outcome and reducing inequality (NICE, 2005). This forms the evidence base for informed decision making and best practice, which are key factors in Public Health. An interesting aspect of how the needs were assessed as indicated by the group is the use of a qualitative approach. According to Mallinson, Popay & Williams (2013), qualitative methods of finding facts is most suitable for understanding human perceptions of their social constructs, and their lived experiences which are subjectively oriented, varying from one individual to another. This understanding enables the planning and delivery of appropriate interventions as clearly demonstrated by the group.
It is noteworthy to mention that the use of surveillance in the course of the intervention programme is another right step in the right direction. It is common knowledge that public health relies primarily on data to produce information relevant to creating action plan and policy development. To this end, Daniel & Hopkins (2013,), point out that with surveillance, an ongoing stream of data is produced that, when appropriately analysed, supports and directs public health actions. Therefore, through surveillance, the data collected at different intervals might help the group in shaping future plans and enhancing case management as the commissioning programme is intended to be re-run every three years.
Furthermore, by assessing their health needs, the presenters have identified the social and well-being effects of the menace on the sufferers and their parents, being vested with a rough idea of what is required of them in terms of human, material and financial resources. Thus, they are able to set priorities for best line of actions to be taken and therefore decide what should be central, marginalized or ignored in the course of the intervention as agreed by Bammer (2013). As a matter of fact, the group have clearly stated methods for tackling the issue. It is most likely that provision of shoes to school children and fumigation of the environment to eradicate the jigger flea would help in preventing against jigger infestation and subsequent children drop out of school and parents absenteeism from work. These effects could only worsen the current poverty situation already prevalent in the communities. Hence, the timely intervention of the ‘commissioners’ could be a welcome adventure at such a time.
Finally, nothing more can be desired from an intervention programme if not to meet targeted health needs of a defined population such as the one in this commissioning scenario. Hence, to check whether or not these needs are actually met, there have to be a functional monitoring and evaluation systems in place. The group have demonstrated in their presentation, some level of understanding in applying this concept in some measurable and practical ways by clearly outlining the methods that would be employed to ensure that both they and their interventional services are on track in delivering best possible quality outcomes during the course of the programme.
Nevertheless, there are a couple of issues that the group failed to put into consideration in the course of the commissioning. This will constitute the next topic of discussion.
By carefully examining the report of the commissioning scenario, one could easily spot the fact that the group excluded mention of the commissioning framework upon which their commissioning was based. A commissioning framework usually serves as a guide for commissioners who aspire to get the best out of their efforts (RCGP, 2010). In the absence of such a framework as the RCGP’s competency framework or the WCC’s framework, it is most likely that commissioners could encounter avoidable setbacks while attempting to address public health issues such as the one in this scenario. For instance, the group failed to set up a commissioning consortium, and by doing so, neglected important key aspects of the commissioning requirements.
Evidently, they ignored the place of partnership and leadership in the process. According to Brady (2012), partnership is expected to bring together a diverse range of skills and resources to achieve improved services for users, where there is a commonality of interest or desire to achieve shared or compatible goals. Without the skills, knowledge and attitudes partnership provides, it could be argued that the group might have challenges in delivering the interventions. Partnership also goes with leadership, a process involving leading an educated, skilled workforce in such a way as to implement changes in public health practice and service delivery with the aim of empowering people and communities to achieve a healthy lifestyle balance (Wilson & Greening, 2009). Leadership therefore, affords the opportunity to assign roles to members of a commissioning group. The group in this scenario is most likely to face the challenge of job negligence and failure to meet deadlines when leadership positions are not clearly spelt out.
Similarly, the group made no mention of procurement procedures that were applied in the intervention process. This leaves one wondering how they were able to identify service providers, and whether or not these providers were competent. With appropriate procurement methods comes bidding competition that allows for maximising use of resources to get best value for money (Adetunji, 2009). As a matter of fact, the transparency and accountability of the process can also be questioned when procurement methods are not well defined. Commissioners who truly know their job are expected to ensure improved services, outcomes and value for money, together with significant cash savings, through the process of procurement and re-procurement (Gandy & Case-Upton, 2013). This feature of effective commissioning is seen to be lacking in this commissioning scenario. The group also failed to state what contract terms and payment methods were used to ensure that all service providers were adequately guided in such a way as to provide best quality products/services that specifically met the needs of the target population. Without signing contracts, the commissioners and contractors are not legally bound by any witnessed written agreement and are therefore at risk of falling into the hands of fraudsters who could make away with the fund allocated for the project.
In addition, although the group stated that they had £480,000 for the project, it is not very clear how this money was spent. According to Last (2007), a budget should show a statement that seeks to reconcile and account for all monetary flows. This should accountably include all sources of income and expenditure, published if possible for public awareness. Accountability of this sort is often a necessary and required tool in measuring the level of commissioners’ competence and transparency in delivering healthcare services. In effect, Nunes, Brandao & Rego (2010), assert that accountability allows for making decision processes in healthcare visible and transparent, especially with regard to the quantity and manner in which resources are sort for and used. Hence, it could have been more appropriate for the group to state in as simple format as possible, the various items and the amount involved in procuring services for the intervention programme.
While these interventions might prove useful, a more practical way would have been to appeal to the government, through the ministry of health, to reduce children’s exposure to sand and dust by attempting to cement or tar most of the play grounds in schools and public places where children often gather to play as it is the case with UK. Better still, they could have introduced jigger-repellents similar to the use of mosquito-repellents against mosquito bites (Day, No date) in malaria prone regions of the world like Sub-Saharan Africa (e.g Nigeria) and parts of Middle East (e.g Paskistan) (Cullin & Arguin, 2011).
This is a hypothetical commissioning scenario in which the ‘commissioners’ have interest in introducing a targeted cholera intervention programme aimed at reducing incidence and spread of the disease. They probably felt the existing health systems were not functional, having identified gabs in service delivery, and therefore set out to intervene. They started off by identifying some gabs in service delivery such as lack of clean water, inadequate diagnosis and treatment, improper waste disposal and illiteracy.
They also formed a consortium and set priorities for the type of services to be rendered. With a budget of one billion shilling, they intend to procure interventional services such as borehole drilling, tent clinics, laboratory equipments and carry out enlightenment campaigns. Next, they made the bidding offer open to the public and qualified companies who met their standards were awarded the contract after they had specified the contract terms and conditions in terms of payment method, quality of service expected and service duration. Quality of service and usability is to be monitored across all levels such as users’ satisfaction, providers’ adherence and professional competence. Finally, they have a feedback system that will provide information for future adjustment for better quality service delivery.
Forming a consortium is usually an interesting aspect of any result-oriented and knowledge-driven commissioning, a responsibility that must be clearly established by efficient commissioners. In this commissioning scenario, efforts have been painstakingly made to ensure that a consortium is formed and as a matter of fact, made to include key players whose decisions and ideas will form the basis for a successful service delivery. Of particular interest is the involvement of service users and gate keepers. Adams (2006) described this as a way of ensuring users are treated with dignity and respect, enabling them feel safe in the service they receive and empowering them to make more informed choices to manage their condition. In this way, community engagement comes to play. This is often an intelligent way of passing the service across to the users in a manner that fosters acceptability and mass participation. A functional consortium such as the one in this scenario should allow for partnership collaboration as members are drawn from different professional backgrounds. It allows for skills and knowledge to be widely shared and spread (NHS, 2013).
The group have also demonstrated a reasonable knowledge of quality service design in a way. The intervention, aimed at reducing the contraction and spread of cholera through provision of clean water as one of the strategies, is about the most effective way of tackling such a health condition since it is reported that contaminated water is one of the primary sources of Vibrio cholera, the causative organism for chorea (Cerda & Lee, 2013). Provision of borehole by the group as a source of water supply can be said to be a primary prevention strategy and a necessary, though not sufficient way to effectively combat the cholera menace. This could help in reducing the number of deaths through cholera as Schneider (2006) reports that there are convincing evidence of association between deaths from cholera and sources of water supply. Hence, it will be absolutely irrelevant for any intervention programme to exclude this all important aspect of tackling cholera outbreak.
As the planning process in healthcare commissioning is important, so also is the procurement process. Procurement involves a systematic way of identifying services and service providers, who make available through a legal contracting procedure, all services required to meet the healthcare needs of a given population (Gandy & Case-Upton, 2013). Procurement is a key aspect of service implementation. As simply stated by Adams (2006), “implementation is extremely challenging and probably demands more of our knowledge, skills and commitment than any other stage of the process”. Therefore, a demonstration of this knowledge and awareness as explicitly displayed by the group is absolutely commendable. For instance, they indicated service specifications, used the open procurement strategy, published names of successful contractors, included time-frame, clearly stated payment methods and invoice validation.
Also noteworthy in this commissioning scenario, is the use of effective monitoring and evaluation strategy by the group. These processes contribute to what is referred to as effective public health action since it is done to achieve desired public health outcomes as observed by Jones (2013). The essence of monitoring is to track performance so that health services can have impacts on perceived problems. According to Jones (2013), evaluation will help the group in shifting efforts to where they are most beneficial, and in some cases, monitoring and evaluation may lead to deconstructing to reconstruct. Monitoring can also help in ensuring that services are not abused but maximised for the benefit of all. By doing so, the group might be able to further identify potential areas of health inequalities and carry out necessary actions to minimize such effects. This basic commissioning understanding has been clearly demonstrated by the group.
The key areas the presenters probably overlooked are as follows;
The presenters have failed to provide evidence for their claims. The background literature indicates that there is a 50% morbidity rate in Arua Town, Uganda due to cholera. However, there is no clue as to how this information can be traced. A key component in public health practice, especially as it concerns decision making for proposed interventions, is often the availability and incorporation of evidence (Gillam & Siriwardena, 2013). Similarly, Brice, Burls & Hill (2013) point out that a good research evidence allows for integrating good information which enables making good public health decisions. It is not usually an effective practice in public health to act on a decision without having sufficient evidence (O’Brien, 2013). Consequently, the group might find it difficult to justify claims and convince stakeholders for sponsorship.
The commissioning scenario is also lacking some level of validity in terms of health need assessment. In this regard, Flowers (2013), notes that it is impossible to improve and measure success of an intervention without being able to conduct health needs assessment. He further stressed that with a properly conducted health need assessment, commissioners should be able to accurately measure burden of disease, assess health equity and inequality, plan effectively, adequately allocate resources and technically evaluate services they provide. Without assessing the health needs of their population, it might be challenging for them to set the right priorities especially in the midst of scarce resources (Wright & Cage, 2013). Health needs assessment also have impacts on the methods of monitoring and evaluating proposed interventions in the long run. According to Scott-Samuel, Ardern & Birley (2013), the nature and content of the project and the perceived importance of this stage of the assessment determine the indicators and methods proposed for monitoring. Therefore, without laying this basic foundation, the group should expect to encounter challenges during the monitoring and evaluation phase of the programme.
The group mentioned that a budget of one billion shilling was earmarked for the proposed intervention programme. Nevertheless, neither did they state where and how this money was sourced nor did they clearly state how the money is being distributed across the various needs identified earlier for meeting the goal of the intervention. An intervention programme is usually expected to be carried out by persons with some measurable experience in management. In fact, Gillam & Siriwardena (2013), suggest that managerial expertise is a necessary requirement for effective purchasing, outlining a wide range of skills commissioners must have to include needs assessment, contracting, performance monitoring, as well as accounting and budget management. Gandy & Case-Upton (2013) also highlighted on issues relating to budgeting and commissioning, stating that there is need for CCGs, the group in this case, to be clear on what budget they are setting aside for procured services and to lower expenditure as much as possible while achieving best possible quality outcomes. Without a good budgeting system, the group might find it difficult to control finance, make confident financial decisions to meet objectives and ensure there is enough money for project continuity. In order words, lack of a clearly defined budget can give birth to sustainability challenges.
As seen in the analysis, the commissioning scenarios were flawed in some respects, especially in terms of not being based on any particular commissioning framework (RCGP or WCC frameworks). They are not having clearly defined budgeting systems in general, and lacking procurement methods and health need assessment strategies for scenario 1 and 2 respectively. However, significant knowledge have been demonstrated by the presenters in many ways. Worthy of mention is the manner in which the presenters in scenario 1 qualitatively assessed the health needs of the population. Presenters in scenario 2 also demonstrated indepth understanding of the need to form a consortium and carry out a well thought-out procurement approaches.
Also, both scenarios have a clear knowledge of monitoring and evaluation processes, key components of effective healthcare delivery. Nevertheless, to practically carry out these interventions, there would be need for the groups to go back to their drawing boards and review their strategies, removing and adding where necessary, aspects that need adjustments. For instance, since the two scenarios are environmentally related, the groups should have solicited for general regular environmental sanitation and personal hygiene as a more cost-effective primary preventive measures against the jigger infestation and cholera outbreak. It is always better, resource-and-time-saving to combat a health problem from the root cause rather than pursuing the problem itself. If possible, pilot interventions should be carry out in a smaller population first, and if successful, then a full-fledged wider launching could be embarked on.
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