Special Report – Commissioning Complex Care

Commissioning Complex Care

S p e c i a l R e p o R t

Commissioning Complex Care – The Key Factors Required for Consideration by GPs

No Simple Answers

Continuity, Quality and Cost of Complex Care

Packaging the Care

Care Management

Sponsored by

Published by Global Business Media

SPECIAL REPORT: COMMISSIONING COMPLEX CARE


Global Business Media Limited 62 The Street Ashtead Surrey KT21 1AT United Kingdom

Switchboard: +44 (0)1737 850 939 Fax: +44 (0)1737 851 952 Email: [email protected] Website: www.globalbusinessmedia.org

PublisherKevin Bell

Business Development DirectorMarie-Anne Brooks

EditorJohn Hancock

Senior Project ManagerSteve Banks

Advertising ExecutivesMichael McCarthyAbigail Coombes

Production ManagerPaul Davies

For further information visit:www.globalbusinessmedia.org

The opinions and views expressed in the editorial content in this publication are those of the authors alone and do not necessarily represent the views of any organisation with which they may be associated.

Material in advertisements and promotional features may be considered to represent the views of the advertisers and promoters. The views and opinions expressed in this publication do not necessarily express the views of the Publishers or the Editor. While every care has been taken in the preparation of this publication, neither the Publishers nor the Editor are responsible for such opinions and views or for any inaccuracies in the articles.

© 2012. The entire contents of this publication are protected by copyright. Full details are available from the Publishers. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical photocopying, recording or otherwise, without the prior permission of the copyright owner.

Contents

Foreword 2 John Hancock, Editor

Commissioning Complex Care – The Key Factors Required for Consideration by GPs 3 Advantage Healthcare Group

Selecting a Quality Care ProviderThe Delegation of Tasks ProcessMonitoring Commissioned Services

No Simple Answers 6 John Hancock

A Variety of CausesHow Much is Known About Complex Cases?Handling Patients with Complex NeedsWhere is Best for Complex Care?

Continuity, Quality and Cost of Complex Care 8 Peter Dunwell, Medical Correspondent

A Matrix of CareQuality Care Built on RelationshipsNot Enough KnownWho Pays the Bill?

Packaging the Care 10 Camilla Slade, Staff Writer

Patient CentredMedical HomeComplex Care is Just That

Care Management 12 John Hancock

Complex Needs are Rarely in IsolationSomeone Who Sees the Big PictureCare Management

References 14

www.PRIMARyCAREREPORTS.CO.uK | 1

Commissioning Complex Care

S P E C I A L R E P O R T

Commissioning Complex Care – The Key Factors Required for Consideration by GPs

No Simple Answers

Continuity, Quality and Cost of Complex Care

Packaging the Care

Care Management

Sponsored by


Foreword

MoST PEoPLE who present themselves to the

health service will do so with one particular

illness or injury for which a fairly specific course

of treatment can be prescribed or commissioned.

However, there are a number of people for whom

one condition can create problems that beget

another condition and start an accumulation of

health care problems. There are also people who

are born with a number of health and disability

issues and, given the lengthening term of life

expectancy in the developed world, there are

people living with conditions that in the past might

have been terminal. All of these together can be

considered as generating complex care needs.

This Special Report examines the main points

required for consideration by GPs in commissioning

complex care. It opens with an article that looks at

the factors to be taken into account in selecting

a quality care provider offering complex care

services in the home, following introduction of

the Health and Social Care Bill 2011. It goes on

to look at how tasks which are normally assigned

to a Nurse, are being delegated to Healthcare

Assistants and points out that, for such delegation

to be successful, choosing an agency with

experience in this process is essential. It stresses

that GP Consortia commissioning care need to be

proactive in obtaining views of the public, patients,

carers and other stakeholders to ensure continuous

improvement in the quality of such care.

Most health services are designed to direct

patients with particular conditions to specific

treatment areas where that condition can be dealt

with. However, patients with multiple and complex

conditions may have to be directed to several or

many treatment areas and that can not only cause

confusion to the patient but may lead to different

treatments actually conflicting and causing yet

another health concern.

For this reason the commissioning of complex

care is a particularly sensitive and important area

in which clinical practitioners can add real value

to a patient’s life, not only through the medication

or therapy that they may prescribe, but also by

ensuring that the patient’s multiple conditions

are managed in a coordinated manner and

understanding of what is going on.

This is not easy and it certainly will challenge the

commissioner’s skills, but in putting into place a

good quality care management scheme and in

arranging things in such a way that the patient

understands that scheme and can even contribute

their thoughts to its development, the GP will help

their patients to feel back in control of their own lives

and will themselves feel considerable satisfaction

at a job well done.

John HancockEditor


2 | www.PRIMARyCAREREPORTS.CO.uK

John Hancock has been Editor of Primary Care Reports since its launch. A journalist for nearly 25 years, John has written and edited articles, papers and books on a range of medical and management topics. Subjects have included management of long-term conditions, elective and non-elective surgery, Schizophrenia, health risks of travel, local health management and NHS management and reforms – including current changes.



Commissioning Complex Care – The Key Factors Required for Consideration by GPsAdvantage Healthcare Group

THE HEALTH and Social Care Bill 2011 has introduced GPs to the world of

commissioning by handing over responsibility for the commissioning of healthcare services across a wide range of clinical and service areas. GPs have become accountable for meeting the reasonable requirements of patients registered with the GP practices who are members of the consortium. This incorporates securing continuous improvements in the quality of services for patients, with particular regard to clinical effectiveness and patient experience, and the power to arrange for the provision of those services for the people for whom the consortium is responsible.

Part of this new remit for GPs involves securing services for patients (adults, children and young people) with complex care requirements who are to be cared for at home, resulting in the requirement for GPs to be engaging with suppliers that traditionally they may not have been involved with, such as private care providers.

Selecting a Quality Care ProviderWith so many providers in the market offering private care at home, but only a select few offering complex care services in the home, it is important to understand the key factors that require consideration when commissioning these care services.

The Care Quality Commission England (CQC), Care and Social Services Inspectorate Wales (CSSIW) and Social Care Social Work Improvement Scotland (SCSWIS) stipulate and inspect all care providers against clear regulations and standards of care, making them the recommended first point of call for GPs seeking a reputable and trusted care provider. Latest inspection reports for every registered care provider can be viewed on the website for the applicable Care Commission, which will provide a good indication of the service quality they provide.

Some care providers will have comprehensive experience of working with PCTs, GPs, Local Authorities, Case Managers and private individuals, giving them a strong understanding of the key considerations required when commissioning bespoke care package for adults, children and young people with complex care requirements. Other smaller or less experienced agencies may not be able to provide the quality of service required.

One of the first key factors that should be considered when exploring private care providers should be the quality of the healthcare professionals they provide.

It is important to understand how a care provider recruits its workers. A quality care provider should follow a stringent recruitment procedure. They need to be compliant with CQC, CSSIW and SCSWIS, and ensure that all Nurses, Care Assistants and Support Workers have the relevant qualifications and experience necessary for the service they will provide.

Checks should be made against each candidate’s work history, experience and qualifications to ensure that there is a complete understanding of the workers’ capabilities and competencies and identify their ongoing training needs. The care provider should also undertake rigorous compliance procedures that need to include, as a minimum:• Enhanced Criminal Records Bureau

(CRB) check.• Checks against the Safeguarding of

Vulnerable Adults (SOVA) and Protection of Vulnerable Children (POCA) registers.

• Obtaining two appropriate references, one of which must be the last or current employer.

• Obtaining a full working history with all gaps referenced.

• Submission of complete immunisation records.

• Annual checks with relevant registration bodies to ensure fitness to practice.



One of the first key

factors that should

be considered when

exploring private care

providers should be

the quality of the

healthcare professionals

they provide. Regular worker supervisions should also

be undertaken to ensure that care staff continue to deliver an excellent standard of service.

Care providers with a comprehensive understanding of delivering complex packages will allocate a Lead Nurse to manage each package of care. They will also give the patient and family a choice in their care team. In these circumstances, profiles of suitable workers should be provided to the patient and family and be discussed with them in detail by the care provider. The patient and family will then be able to provide introductions of their shortlisted selection of healthcare professionals. This should include a core group of workers and some additional workers for contingency planning.

In addition to how the care provider recruits its workers, it should also be understood how the provider delivers its worker training and manages ongoing regulatory compliance.

A quality care provider will manage its care teams by undertaking regular supervisions, peer group meetings and annual appraisals, as well as annual training updates and health forms. Providers with more experience in delivering complex packages are also likely to conduct a training needs analysis on all workers assigned to a complex care package and, following this analysis, devise a training course around the specific requirements of the patient and the training requirements of the care team.

It is important that shadow shifts are also undertaken with the care team to enable them to learn the patient’s routine and to start the delegation process (this is where tasks are delegated from the Registered Nurses to a carer), with the Lead Nurse in the package.

Finally, one of the most important key factors to consider when commissioning complex care to a private care provider, is the provider’s commitment to quality and its quality assurance systems.

A high quality and trusted care provider should deliver a comprehensive internal quality assurance system, which is continually reviewed and monitored to make certain they offer a service that is not only highly dependable, but also ensures that the well being of every patient is their main priority. This will commence with initial care planning.

It is imperative that the care provider completes a holistic, outcome based care plan that should be completed by a suitably trained and qualified individual in partnership with the patient and family/carers (where appropriate). This individual should be a Registered Nurse with relevant skills wherever there is a clinical need.

The completed care plan should always be discussed with the patient or representative, who should sign the final version to agree the contents. It is then important that the care provider has systems in place to review the patient’s care plan at least every 6 months, or whenever there is a change in the patient’s condition. In addition, a high quality care provider will undertake regular quality monitoring visits, including spot checks on the care team and quarterly performance reviews.

The Delegation of Tasks ProcessIn addition to its quality assurance systems and the workers that it provides, it is also important that the care provider implements a cost-effective and economic model for the delivery of its care services. Some more experienced providers



of complex care services may employ this through the delegation of task process, which involves the tasks normally assigned to a Nurse, being delegated to a Healthcare Assistant (HCA).

The role of the HCA is becoming increasingly important in supporting the Nurse in most healthcare environments, especially in the patient’s home. Changes in the way healthcare services are delivered have seen the HCA taking on more of the work previously done by the Nurse. Much of this is through delegation from the Nurses themselves.

Successful task delegation can bring many benefits, such as a reduction in cost of the package of care. It can also be a rewarding and positive experience for both the HCA and Nurse. However, for the delegation to be successful,

careful consideration needs to be given to a number of issues, therefore choosing an agency with experience in this process is essential.

Monitoring Commissioned ServicesThe monitoring of services commissioned is another duty of the Consortium, with a view to securing continuous improvements in the quality of services for patients. GP consortia will need to be proactive in seeking out the views and experience of the public, patients, their carers and other stakeholders, especially those least able to advocate for themselves.

‘Patients must be at the heart of everything that we do, not just as beneficiaries of care, but as participants in its design’ Andrew Lansley MP

The recipients of care are often the ones that are not listened to, but can provide valuable information for service design if time is taken to engage with them. GP Consortia will need to commission services that consistently set out to understand then improve their patient experience.

Question the methodology engaged by your service provider to review complaints, identify trends and take corrective action to improve the service. Is a Customer and Worker satisfaction survey undertaken by the service provider? What did they do with the feedback and how was that feedback used to review and implement change if required?

Your own observation supported by the annual Care Commission Inspections will enable the GP Consortia to obtain a clearer picture of the service the provider is delivering. An annual Quality Review/Audit of key areas will provide this so it is important to ensure it is included in a Service Level Agreement.

The ultimate aim of all those GP Consortia commissioning care is to ensure effective, efficient and economic provision of care whilst securing continuous improvement in the quality of primary care. Taking time to research these key factors will assist in achieving this objective.

GP consortia will need

to be proactive in

seeking out the views

and experience of

the public, patients,

their carers and other

stakeholders, especially

those least able to

advocate for themselves.



Complex needs put

an enormous strain on

healthcare systems and

add layers of complexity

to the management

of those patients’

care as well as to the

commissioning process

for which GPs are

increasingly responsible.

No Simple AnswersJohn Hancock

AN INCREASING number of patients today are presenting with complex

healthcare needs; that is a number of different conditions, each of which requires treatment and management but which also have to be considered in the context of the whole person. And this is not just an issue with older people. Increasing numbers of premature babies are surviving birth at ever earlier terms but often with multiple congenital issues (including learning and physical disabilities) which accompany them into childhood and adult life. Complex needs put an enormous strain on healthcare systems and add layers of complexity to the management of those patients’ care as well as to the commissioning process for which GPs are increasingly responsible.

A Variety of CausesThe above are examples of what may be considered ‘naturally occurring’ complexity but there are numerous causes that can create a need for complex care. Learning disability, personality disorder, autism… all can create conditions for multiple health profiles, especially if the disability impacts adversely on a patient’s ability to take care of themselves, including administering medication.

Other causes of health problem complexity may include lifestyle patterns such as drug and alcohol abuse, and social problems including economic welfare and homelessness. GPs may not often experience patients with complex problems and almost certainly won’t often experience patients with a specific multiplicity of problems. Dr Clare Royston, medical director at Care Principles, explains in the case of learning disability;

“Due to the relatively low number of vulnerable learning-disabled patients, GPs are likely to have limited experience of commissioning services. There is a need for a specialist commissioning body…”1

Dr Royston cites learning-disabled patients but, in reality, the comment applies to most complex conditions.

As a first step towards managing their care in an appropriate manner, it is often useful to categorise patients with complex needs into broad groups such as2:• Older people;• People with physical disabilities;• People with mental health problems;• People with learning disabilities;• People with sensory impairments;• People with HIV and AIDS;• People with alcohol-related problems.

These categorisations help put together specialist teams or identify specialist workers who can work with people in these groups. GPs, as commissioners of services, will need to know of and form strong working relationships with specialist teams and workers in their locale.

The Royal College of General Practitioners (RCGP) in Wales tries to summarise the roots of complex needs3: “Older people tend to suffer from more chronic conditions while population movements alter community cohesion and epidemiology…” and goes on to tie the prevalence of diseases often found in complex cases, like diabetes, hypertension and obesity, to the increasing consumption of fast foods, smoking, lack of exercise and poor lifestyle habits as well as highlighting the impact of alcohol, misuse of drugs, changes in family dynamics, and increasing dependency on social care and health benefits as leading ultimately to a ‘medicalization’ of people’s problems.

How Much is Known About Complex Cases?Although not directly applicable to the UK, research in the USA has shown that, while people with multiple chronic conditions are a growing segment of the population, little is, as yet, known about how chronic conditions cluster and the ramifications of having specific combinations of chronic conditions4. For GPs, understanding how complex conditions will affect the effect of individual conditions within that health matrix will add considerably to their commissioning capabilities and the quality of

Patients with Complex Care Needs will Challenge GPs’ Commissioning Skills



patients’ outcomes. It will also inform decisions on treatments and drug prescriptions, themselves a complex element in the management of complex conditions.

The RCGP again sums up the key position of GPs, in this as in most areas of healthcare, to provide the link between patients with complex needs and the often fragmented health and social care provisions that address individual needs within that complexity5;

“… People with complex problems must navigate increasingly fragmented health and social care provision to get their care. There is a risk that, when patients receive different aspects of their care from different parts of the system, no one takes overall responsibility. GPs accept this responsibility and can often prevent expensive duplication of investigations or uncoordinated care from different providers.”

Handling Patients with Complex NeedsThe National Institute for Health and Clinical Excellence (NICE) believes very strongly that healthcare professionals and nonclinical staff who work in GP practices should receive training to help them with handling patients affected by some of the behavioural and social causes of complex health needs. There are numerous NICE guidelines on the subject but one that sets out very clearly how to handle people with complex conditions brought about by lifestyle and social factors is the 2010 clinical guideline ‘Pregnancy and complex social factors’6. The guideline addresses practical issues such as that people who misuse substances may also be anxious about the attitudes of healthcare staff and the potential role of social services in their life, they may be easily overwhelmed by the involvement of multiple agencies and may also lead chaotic lives which means that a variety of methods are needed to remind them of upcoming and missed appointments – sending text messages is becoming increasingly popular.

In another clinical guideline looking at depression combined with chronic physical health problems, the RCGP points out that,

“In addition to physical illness, a wide range of psychological and social factors, which are not captured well by current diagnostic systems, have a significant impact… [it is important] to consider both personal past history and family history of depression when undertaking a diagnostic assessment”7.

Where is Best for Complex Care?Whatever the nature of the patient’s complex of conditions or how they have come about, the GP’s challenge will be to commission appropriate care. There are a number of options ranging from full hospitalisation to independent living at home but with support. Hospital might be the option for extreme cases of illness but is not necessarily an ideal environment for long- term care, even with complex needs. As institutions, hospitals may not be best equipped to deal with some of the behavioural symptoms of complex conditions8.

When considering other specialist institutions, commissioning GPs need to consider what services those institutions offer compared to the needs of their patient. For instance does the institution offer learning disability support and does it have a clear methodology for communicating with patients so that they can be part of discussions about their treatment program?

If the patient is to remain at home, is sufficient attention paid to the needs of their family and/or carers, and are systems in place to ensure their supported independence9? And last but not least, is funding provision in place10? As Alison Giraud-Saunders, consultant at the Foundation for People with Learning Disabilities (FPLD) explains;

“… it shouldn’t matter where the money comes from. But different sources of funding come with different rules and it’s really important to understand what these may mean.”

The needs of people with complex conditions poses a particular challenge for commissioning GPs for which the response has to be, as is so often the case, you can never have too much information.



Continuity in the

consultation process

often makes it easier for

the patient to explain

how they feel in what

becomes a familiar

context. That familiarity

with what is normal

for a particular patient

also makes it easier

for the GP to deal with

unexplained symptoms.

Continuity, Quality and Cost of Complex CarePeter Dunwell, Medical Correspondent

THE RoyAL College of General Practitioners (RCGP) regards continuity

as fundamental to the building of trust with any patient and particularly with one who has complex needs11. Whether it’s relationship continuity (clinicians and care workers) or management continuity (a plan that is understood and consistently applied) this is a very important part of a successful treatment relationship for a patient with complex needs and the glue that holds together a successful healthcare plan. In his White Paper, ‘Supporting people with long-term conditions’ David Colin-Thome, National Clinical Director for Primary Care identified as key elements in such a plan;

“… enabling and supporting health, independence and well-being; rapid and conventional access to high-quality, cost-effective care; and putting more people in control of their own health.12”

A Matrix of CareHowever, as Siri Carpenter wrote in the March 31, 2009 New York Times13;

“time pressures intensify the doctors’ predicament. A typical… appointment leaves too little time to weigh the risks and benefits of a complex treatment plan, much less to fully consider the patient’s preferences and priorities. “We don’t actually know how to weigh evidence across diseases,” said Dr Boyd of John Hopkins, “and we also don’t know the best ways of communicating to patients what we do and don’t know.”

Inevitably patients with complex needs will need a matrix of interlocking care programmes delivered by a number of different health and care deliverers. It is clearly set out in ‘Primary Complex Nursing Responsibilities’ an article on eHow14.

“Each patient will receive a unique healthcare plan to alleviate any medical issues… Although the plan is presented by the doctor, the nursing staff is responsible for implementing all necessary components…”

Quality Care Built on RelationshipsNurses are a key liaison between patient and doctor because they see patients more often, but even more so in complex cases15. Again, it is continuity of relationship that is so important in complex cases. However GPs must be alert to continuity of relationship not leading them to diagnose based on assumption bred by familiarity16. An RCGP paper (see below) emphasises the importance of continuity in the consultation process which often makes it easier for the patient to explain how they feel in what becomes a familiar context. That familiarity with what is normal for a particular patient also makes it easier for the GP to deal with unexplained symptoms.

The RCGP believes that GPs are well placed to deliver this quality and continuity of service17;

“UK GPs are expert generalists who value their role in coordinating in integrating care designed round the needs and circumstances of each patient. They deal with undifferentiated problems and illnesses that occur in different biological systems at the same time. They care for all, regardless of age and gender… Management continuity… concerns good communications between healthcare team members, or between providers, and supports the concept of the patient’s care pathway through the system.”

Generalists are believed to be the best equipped to care for people with complex multisystem problems because, while they may not be the experts in any particular condition, they know the experts to consult in each case and, overall, they know the patient and so are able to ensure a high quality of life18. This from the RCGP Paper ‘Medical Generalism’ which also addresses the issues of working within a multidisciplinary primary care team – very important when dealing with patients with complex needs. So important is this as an element in general practice that the overall winners of the RCGP Enterprise Awards in 2010 were Upton Surgery, Worcestershire19

Even with a complex case, the patient-clinician relationship will be the most important factor in treatment quality



for the “practice’s complex care team [which] provided a multiagency approach to supporting patients with acute needs…”

Not Enough KnownAs Siri Carpenter in the New York Times (see above) put it;

“In a medical system geared towards individual organs and diseases there is no champion for patients with multiple illnesses… Because so little research includes complicated patients, physicians have little scientific evidence on which to base their care.”

That is where the British GPs’ patient relationship is such an invaluable tool in complex cases.

Of course, with patients who have complex needs, the basic tenets of good practice still apply. For instance, children who need complex packages will often also be disabled and thus these decisions would engage discrimination law duties under the Equality Act 201020. It is also important that the rights of all patients with complex needs are respected and that they are communicated in a way which is accessible to them. The 2011 case of the abuse of adults with learning difficulties at Winterbourne View residential hospital in Bristol highlighted some of the pitfalls that can dog the process of commissioning complex care.

Who Pays the Bill?As always these days, the matter of funding will rear its ugly head and cannot be ignored in commissioning complex care. Who pays the

bill often depends upon the specific nature of the condition so that, in children with complex needs, where those needs are physical or medical, a significant proportion of the charge will fall to the health service while, for a child with learning difficulties and challenging behaviour but no specific mental condition, most of the funding will probably come from social care and education. In complex cases at any age, care close to or in the home is the preferred option for professionals and patients; it also offers cost benefits.

The shares of funding born by the NHS and, largely, the local authority, will have to be properly agreed and established – a more complex task where complex care is required. But wherever the funding might be sourced, those commissioning complex care need to understand how it will affect their patients’ quality of outcomes.

‘Complex care’ is what it says but commissioning GPs need not fear it; they need to apply the same care for continuity and quality that applies throughout the practice.

Generalists are believed

to be the best equipped

to care for people with

complex multisystem

problems because, while

they may not be the

experts in any particular

condition, they know the

experts to consult in each

case and, overall, they

know the patient.



THE MAIN points to consider when commissioning complex care packages

will be familiar: good practice; quality standards; training and development for practitioners, including supervision; identifying and acting on issues arising in the provision of continuing care.

Patient CentredThese points have all been taken from the Department of Health’s ‘National Framework for Children and Young People’s Continuing Care’21 but will be equally true for any complex care provision. One key matter that the framework highlights about patients who have complex needs, especially but not exclusively young people, is that they will almost certainly need a continuing care package when they have, “… needs arising from disability, accident or illness that cannot be met by existing universal or specialist services alone.” One thing that the ‘National Framework… ‘ makes clear is that, wherever a need for continuing care is established, bespoke commissioning will be required and that will be true for any patient in need of complex care. It does place an additional burden on the commissioning GP inasmuch as, while the principles of quality of care, patient involvement, regular monitoring to ensure that the plan remains relevant, etc. ,still apply, each complex care commission will be unique. The upside is that it will add to a GP’s overall experience.

Medical HomePatients with complex needs do take up a disproportionate amount of any health service’s time and resources but the primary care system in the UK does a better job than most ensuring that patients receive the care that they need. In 2011 the Commonwealth Fund conducted a ‘Survey of Patients with Complex Care Needs in Eleven Countries22’ which found that,

“Sicker adults in the UK and Switzerland were the most likely to have a medical home [an accessible primary care practice that knows their medical history and helps coordinate care]: nearly three-quarters were connected to practices that have medical home characteristics,

compared with about half in most of the other countries.”

Having a medical home generates all sorts of benefits including a likelihood that any care plan will be patient-centred and that the professionals involved will make a lot of effort to ensure that the patient understands what it is that they need and contributes to the creation of the plan. For this purpose, commissioners might wish to make use of visual communication aids such as the Mayer-Johnson LLC Picture Communication Symbols. Simple graphics combined with simple language explanations help to avoid unintelligible professional jargon which might give any patient, and especially one with complex needs, the sense that they were not involved in the care planning.

Coming back to the issue of resources; as Browne Jacobson LLP explains;

“… the issue which is perhaps of most concern to… Commissioners of complex care and fully funded packages of care under the National Framework is cost.”23

The lawyers go on to highlight some of the issues faced by commissioners handling packages of complex and fully funded continuing care. These range from spot purchasing services in relation to a number of separate patients but from the same provider, to using pooled budgets and the implications of ‘out of area ‘ placements.

Also, there are different decision and funding mechanisms applicable to adults and children in need of complex care. These can lead to quite challenging commissioning processes and so GPs should do their research before embarking on such a process. One place to look is the websites of legal practices (see Browne Jacobson LLP above) and, in this also, No5 Chambers has lots of useful information on its website24.

Complex Care is Just ThatAll of this should not divert attention from the fact that, at the heart of any planning and commissioning process will be a potentially vulnerable person with one or more disabilities plus, in the case of complex needs, there will be a clustering of cases towards the extremes of the age range – children and young people, and the elderly. It is important that healthcare services

Patients with complex

needs do take up a

disproportionate amount

of any health service’s

time and resources but

the primary care system

in the UK does a better

job than most.

Packaging the CareCamilla Slade, Staff Writer

Commissioning complex care involves a lot more than simply choosing an appropriate treatment – complex needs demand complex plans



promote continuity and integration of services in line with the experience of some patients and the multiple chronic conditions suffered by a growing the number of patients25. That is sometimes easier said than done. In a New York Times March 31, 2009 article by Siri Carpenter, Dr Cynthia M Boyd, a John Hopkins University geriatrician said of one complex patient;

“doing right by patients like this is tremendously challenging. Would [the patient] get the most benefit from lowering her blood pressure or cholesterol level, or from being treated for her osteoporosis, or from taking warfarin for stroke prevention? Or is it more important to treat her depression so she can manage her overall health better, or to try to improve her ability to physically get around?”26

The article highlights the dangers of treating one disease in isolation which can make another condition worse.

Dr Boyd mentions depression and NICE views the treatment of depression as having the

potential to increase the quality-of-life and life expectancy of patients with complex conditions, as NICE clinical guideline 91 – ‘Depression with a chronic physical health problem’27 puts it.

Again, coming back to young people, there are a number of other factors that add further layers of complexity to what may already be a complex case. As the National Framework… (see above) explains;

“… childhood and youth is a period of rapidly changing physical, intellectual and emotional maturation alongside social and educational development. All children of compulsory school age should receive suitable education, either by regular attendance at school or through other arrangements. There may also be social care needs.”

And there is, of course, the need to maintain relationships between children or young people and their family and other carers.

In short, commissioning complex care is never going to be a simple process.



“...this high-risk group of

patients needs not only

good management of

their specific diseases,

but also a holistic

overview to be taken

of their full health and

social care needs.”

Complex Needs are Rarely in IsolationIn 2007, over 15 million people in the UK were living with at least one long term condition, i.e. a condition that cannot, at present, be cured, but can be controlled by medication and other therapies28. The problem is that often these long-term conditions, their genetic causes or the diseases that cause them, or the lifestyle choices at their root, can cause other conditions. The Department of Health paper, ‘Case management for patients with complex long-term conditions and high-intensity needs29’ explains:

“As patients develop multiple long-term conditions, their care becomes disproportionately complex and can be difficult for them and the health and social care system to manage… Evidence has shown that intensive, on-going and personalised case management can improve the quality-of-life and outcomes for these patients, dramatically reducing emergency admissions and enabling patients who are admitted to return home more quickly.” It goes on to say, “… this high-risk group of patients needs not only good management of their specific diseases, but also a holistic overview to be taken of their full health and social care needs.”

Someone Who Sees the Big PictureAnd it’s not just in the UK that this view prevails. “Understanding how to care effectively for persons with multiple chronic conditions is among the most important challenges our health care system faces30.” This from the National Center for Biotechnology Information (NCBI) in the USA. As one patient interviewed for a New York Times article on complex care put it:

“good luck and a lot of sleuthing on my part has given me doctors whom I trust and who are mostly aware of interactions among the drugs they prescribe. But what’s missing is someone who can look at the big picture and see my health as a whole… As our population ages, we need some kind of overseer to juggle all the diagnoses and prescriptions and look the conflicts and duplications.”

There is definite need for management.But it is also true that people with long-

term and multiple conditions will have better lives when they are supported to take care of their conditions themselves and that is more likely to happen if patients have a clear understanding of their condition and what they can do about it. A strong principle these days is ‘Your health, your care, your say.’ In the UK again, NICE31 (National Institute for Health and Clinical Excellence) believes that, as part of that management, good communication between practitioners and patients is essential and should be supported by evidence-based written information tailored to the patient’s needs.

Care ManagementThe Robert Wood Johnson Foundation’s (RWJF) Synthesis Project has identified care management as, “a delivery innovation that may be able to reduce costs while improving quality for people with multiple chronic conditions.32” In this case, care management is defined as a set of activities designed to assist patients and their support systems in managing medical conditions more effectively. Put like that it sounds deceptively simple but extend the definition to include ‘improving patient’s functional health status, enhancing coordination of care, eliminating duplication of services, reducing the need for expensive medical services and increasing patient engagement in self-care,’ and care management looks to be quite a complex issue. And the start of it, according to RWJF, is in identifying patients most likely to benefit, i.e. those whose quality-of-life, likely outcomes and the cost of whose treatment is likely to be improved as a result of a care management programme that enables them to remain in their own home.The project also offers a useful guide to the keys to successful care management.In-person encounters: Person-to-person encounters, including home visits, are necessary features of effective care management. Care management relying solely on telephone encounters has not shown success.Training and personnel: Programmes with specially trained care managers who have a

Care ManagementJohn Hancock

The better managed a care programme is, the more likely it is to deliver quality outcomes for all involved



relatively low workload are most successful. Most care managers are registered nurses who work as part of a multidisciplinary team.Physician involvement: Placing care managers with physicians in primary care practices may help facilitate physician involvement.Informal caregivers: Patients with complex health care needs, particularly those with physical or cognitive functional decline, often need the assistance of informal caregivers to actively participate in care management.Coaching: Coaching involves teaching patients and their caregivers how to recognise early

warning signs of worsening disease.In the UK NHS, much of this programme

is delivered by the Community Matron33 who, as the Department of Health pamphlet for patients says:

“… is someone who is there for you and will make sure your views are heard, so you can feel in control when decisions are being taken about your health, your well-being, and your life.”

Community Matrons work across health and social care services and the voluntary sector to ensure that patients with complex needs receive services that are integrated and complimentary.

For all people with long-term and complex care needs, wherever possible, care based in a home environment, whether their family home or a specialist unit, is going to be the best solution for their lifestyle quality and as far as the cost of care delivery is concerned. Innovative solutions include Wakefield’s Telecare scheme in which flats have been equipped with a full range of telecare equipment so that residents can summon support immediately and can speak with their support worker at any time.

Also a degree of independence will help tackle depression which is, according to NICE, 2 to 3 times more common in patients with a chronic physical health problem than in people who have good physical health. In a similar way, involvement in decisions about their treatment will help to avoid depression, focusing on a sense of powerlessness in one’s own life.

As with any complex problem, the commissioning of complex care will benefit from a methodical and well-managed approach by those doing the commissioning.

Community Matrons work

across health and social

care services and the

voluntary sector to ensure

that patients with complex

needs receive services

that are integrated

and complimentary.



References:1 Learning Disability Today

http://www.ldtonline.co.uk/2011/04/people-with-complex-needs-require-a-specialist-commissioning-body-expert-claims/

2 Cumbria County Council http://www.cumbria.gov.uk/adultsocialcare/adults/complexneeds.asp?Layout=Print

3 RCGP (Wales) http://www.rcgp.org.uk/pdf/Wal_RCGP_Wales_Next_Steps_Document.pdf

4 National Center for Biotechnology Information http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2150598/

5 RCGP http://www.rcgp.org.uk/pdf/RCGP_Continuity_of_Care.pdf

6 NICE: ‘Pregnancy and complex social factors: A model for service provision for pregnant women with complex social factors’ http://publications.nice.org.uk/pregnancy-and-complex-social-factors-cg110

7 NICE ‘Depression in adults with a chronic physical health problem’ http://www.nice.org.uk/nicemedia/live/12327/45909/45909.pdf

8 Primary Complex Nursing Responsibilities http://www.ehow.com/list_6905788_primary-complex-nursing-responsibilities.html

9 The Scottish Government, ‘Increase the level of older people with complex care needs receiving care at home’ http://www.scotland.gov.uk/About/scotPerforms/partnerstories/NHSScotlandperformance/Complexcareneeds

10 Learning Disability Today http://www.ldtonline.co.uk/complex-needs/

11 RCGP, Promoting Continuity of Care in General Practice http://www.rcgp.org.uk/pdf/RCGP_Continuity_of_Care.pdf

12 ‘Supporting people with long term conditions http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Healthcare/Longtermconditions/DH_4128521

13 ‘Treating an Illness Is One Thing. What About a Patient With Many? http://www.nytimes.com/2009/03/31/health/31sick.html





18 ‘Medical generalism’ http://www.rcgp.org.uk/pdf/Medical%20Generalism%20-%20Why%20expertise%20in%20whole%20person%20medicine%20matters.pdf

19 GP Enterprise Awards 2012 http://www.rcgp.org.uk/pdf/GP%20Enterprise%20Award%202012.pdf

20 No5 Chambers http://www.no5.com/news-publications/publications/lawfully-commissioning-complex-packages-of-care-for-children-who-pays-for-what

21 ‘National framework for children and Young People’s continuing care’ http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_116469.pdf

22 Commonwealth Fund ‘Survey of Patients with Complex Care Needs in Eleven Countries’ http://www.commonwealthfund.org/Publications/In-the-Literature/2011/Nov/2011-International-Survey-Of-Patients.aspx?view=print&page=all

23 Browne Jacobson http://www.brownejacobson.com

24 No5 Chambers http://www.no5.com/news-publications/publications/lawfully-commissioning-complex-packages-of-care-for-children-who-pays-for-what

25 Multiple Chronic Conditions: Prevalence, Health Consequences, and Implications for Quality, Care Management, and Costs http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2150598/

26 ‘Treating an Illness Is One Thing. What About a Patient With Many? http://www.nytimes.com/2009/03/31/health/31sick.html

27 NICE http://www.nice.org.uk/nicemedia/live/12327/45909/45909.pdf

28 The Synthesis Project http://www.rwjf.org

29 Department of Health, Case management for patients with complex long-term conditions and high-intensity needs http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/Browsable/DH_4966006

30 Multiple Chronic Conditions: Prevalence, Health Consequences, and Implications for Quality, Care Management, and Costs http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2150598/

31 NICE http://www.nice.org.uk/nicemedia/live/12327/45909/45909.pdf

32 The Synthesis Project http://www.rwjf.org

33 Department of Health, ‘Community Matron’ http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4131690.pdf

http://www.rwjf.org/files/research/52372.caremgt.brief.pdf

http://www.rwjf.org/files/research/52372.caremgt.brief.pdf

primary care Reports

the leading specialist online research and networking resource for General practitioners and other senior primary care professionals.

• Uptotheminutenewsandothercontentavailabletoallsiteusersona free-of-charge, open access basis.

• QualifiedsignedupmembersareabletoaccesspremiumcontentSpecialReports and interact with their peers using a variety of advanced online networking tools.

• Designedtohelpusersidentifynewsolutions,understandtheimplications of different choices and select the best options available.

• ThoughtLeadership–Adviceandguidancefrominternationallyrecognisedprimary care key opinion leaders.

• PeerInput–Contributionsfromseniorprimarycareprofessionals.

• IndependentEditorialContent–Expertandauthoritativeanalysisfrom award winning journalists and leading industry commentators.

• UnbiasedSupplierProvidedContent.

• Designedtofacilitatedebate.

• Writtentothehighestprofessionalstandards.

Visit: www.primarycarereports.co.uk

Documents

Special Report – Commissioning Complex Care