A rapid review of the impact of commissioning on service use, quality, outcomes and value for money: implications for Australian policy

Additional keywords: contracting, planning, primary health care, purchasing.

Commissioning is a term that has only recently gained currency in Australian policy. While there is no single authoritative definition of commissioning (Newman et al. 2012; Dickinson 2015), it is defined broadly as the process of planning, purchasing and monitoring services for a population (e.g. geographically defined), subpopulation (e.g. people with diabetes in a given region) or individual client (often in the context of care coordination). The core process of commissioning involves three main areas of activity: strategic planning, contracting services, and monitoring and evaluation (Fig. 1).

Fig. 1.  Elements of the commissioning cycle. Adapted from SA Health Clinical Commissioning Intentions (2013–17) (O’Brien 2013).

Commissioning health services emerged in the United Kingdom (UK) in the late 1980s (Bovaird et al. 2012) and has been followed by other countries, for their own reasons. In the UK, commissioning was implemented in an attempt to use market forces and introduce non-government and private providers to bring innovation into a highly centralised system. In parts of Eastern Europe, it has been used to move away from exclusively state-run health services towards greater private sector provision. In the United States (US) it has been used to organise affordable health care for people within specific health insurance arrangements (military veterans who have received care from the Veteran’s Health Administration, employees, Medicare recipients and members of Health Maintenance Organisations).

The policy reasons for considering a greater role for commissioning in Australia are described in the Reform of the Federation discussion paper (Australian Government 2015) and the paper by the Primary Health Care Advisory Group (2015). Moving away from a system that rewards occasions of service to one that places greater emphasis on the quality and cost of service delivery is an important driver. In the context of an uncapped, largely fee-for-service primary healthcare system for private medical or allied services, a significant intention is to improve access to care for specific patient groups while keeping a cost-effective, sustainable system. In terms of service provision, there is a need to offer more appropriate care packages for older people or those with chronic conditions or complex needs, and to provide services that will avoid or reduce hospitalisation. This requires the ability to combine different sources of funding, and rationalise often conflicting systems of accountability between the Commonwealth and the states. Pooling funds and jointly commissioning services is one way of achieving this. Further impetus comes from the interest of private health insurers in providing support services for members who may become users of hospital services.

There have been several reviews of different types of commissioning in the healthcare sector but limited consideration of commissioning as it might be applied in the health system in Australia. This paper draws on a rapid systematic review of the evidence on the effectiveness of commissioning conducted in July and August 2015 to consider lessons for Australia. The specific research questions were:

1. What national and international forms of commissioning primary care at jurisdictional or local/regional level have been shown to be effective, for which population groups and in what contexts?

2. What are the impacts, risks and unintended consequences associated with these?

Drawing on the evidence, we consider which aspects of commissioning could be applied in Australia and what regulatory, governance, policy and funding arrangements might be required to support them.

A rapid review was conducted, consistent with accepted methodology (National Collaborating Centre for Methods and Tools 2014). The project team put together a comprehensive search strategy and set of search terms (Box 1). Searches were conducted in Medline, Embase, CINAHL, Informit and the Cochrane Database of Systematic Reviews. Hand searching of key journals (Health Policy, Health Services Research and Policy, and Health Economics) and citations from key papers was also conducted. Relevant website searches from Australia, the US, the UK, New Zealand and Europe, and consultation with key experts in each of these countries, identified grey literature.

Only studies conducted since 2005 that incorporated key aspects of commissioning of primary healthcare services with a focus on purchasing services at the primary and acute care interface or chronic disease management, disability or mental health were included in the review. Studies had to report on key elements or activities of a local/regional level commissioning process as well as impacts on processes of care, client outcomes, cost containment, patient satisfaction or barriers and facilitators to implementation of commissioning. Qualitative and quantitative studies were included. Studies were excluded if they did not explicitly include some elements of commissioning and report on at least some impact, outcome or barrier/enabler to implementation (inclusion and exclusion criteria are contained in Appendix S2 available online as supplementary material).

Five researchers (JM, KG, MH, RK, CJ) extracted data from the peer-reviewed literature. The quality of studies was not formally assessed. The commissioning cycle (planning, contracting, monitoring) formed a framework for analysis of the literature and impacts were assessed at individual, subpopulation or population levels.

Following exclusion of duplicates, 444 papers were identified in the initial search and, of these, 408 that did not meet our criteria were excluded (Fig. 2). Many of these were descriptive papers that drew on expert opinion to describe various approaches, related policies or reforms, or which explored some aspect of commissioning such as clinician involvement. Several of these papers were retained as background to the review and, together with 20 grey literature reports, were used to consider the regulatory, governance, policy and funding arrangements that might be required to support commissioning in Australia. Thirty-six papers were reviewed.

Fig. 2.  Search strategy results.

Of the 36 studies included, 30 were from UK (including one comparison of commissioning in England and Germany), one from Finland, four from US, one from New Zealand. No studies from Australia or Canada were identified that met our inclusion criteria. This may be because commissioning has only recently emerged as a major policy issue in these countries.

As shown in Table 1, included studies covered a range of different commissioning organisations, including primary care trusts (PCTs), fundholding practices, practice-based commissioning (PBC), clinical commissioning groups (CCGs) and joint commissioning in the UK, municipal contracting in Finland, managed care and accountable care in the US, and district health boards in New Zealand. Studies were predominantly qualitative, involving cases studies and interviews and/or surveys of the perceived impacts, levels of engagement, success factors, barriers and enablers to commissioning, or satisfaction among different stakeholder groups. Five quantitative studies assessed the impact of commissioning on cost containment and service use, and there was one cluster randomised controlled trial on the impact of pay-for-outcomes on smoking cessation rates.

Table 1.  Included studies by commissioning organisation, study type and focus
AFR, accountability for reasonableness; APMS, Alternative Provider of Medical Services; CCG, clinical commissioning group; DHB, district health board; HLP, Healthy Living Pharmacy; PBC, practice-based commissioning; PBMA, Program Budgeting and Marginal Analysis tool; PCT, primary care trust; PDSS, Personal Dental Service Scheme; NHS, National Health Service; RCT, randomised control trial

Sixteen studies addressed at least one of the elements of the commissioning process (Table 2). No studies of monitoring were identified. In relation to planning, there was a strong focus on the importance of comprehensive needs assessment for groups and populations (Elvey et al. 2006; Shaw et al. 2013). Six studies addressed priority setting and rationing. Marks et al. (2011) found limited use of priority setting tools (decision support) for resource allocation. Priority setting needs to be embedded in routine planning and budgeting processes (Robinson et al. 2012a, 2012b) and provide support for disinvestment as well as investment decision making (Rooshenas et al. 2013). Shaw et al. (2013) found that commissioning care, especially long-term care, is time consuming and complex, and supported best by an incremental approach.

Table 2.  Study findings on the elements of commissioning for individuals, subpopulations and populations
AFR, accountability for reasonableness; APMS, Alternative Provider of Medical Services; CCG, clinical commissioning group; PBC, practice-based commissioning; PBMA, Program Budgeting and Marginal Analysis tool; PCT, Primary Care Trust

Studies of contracting focused predominantly on partnerships supporting commissioning of specialist services for subpopulation groups (Freeman and Peck 2006) and the impact of service and contract design on improving models of care. Slater and White (2007) found that PBC supported service redesign to improve models of care. Freeman and Peck (2006) reported that service users perceived that commissioning in PCTs had improved specialist models of care for mental health, and drug and alcohol services. CCGs were not supportive of outsourcing contracting or other support functions as these were perceived to potentially lead to fragmentation and increased transaction costs (Petsoulas et al. 2014). Alternative Provider of Medical Services (APMS) contractual processes were time consuming, expensive and perhaps unsustainable (Coleman et al. 2013).

Ly and Glied (2014) showed that in the US, contracting opportunities conferred significant benefits on physicians, although they added modest costs in terms of time spent outside patient care and perceived lower adequacy of time with patients. Simplifications that reduce the administrative burden of contracting may improve care by optimising allocation of physician effort.

A range of services can be purchased for individuals on the basis of an individual assessment, such as through a care plan, for specific subpopulations or groups on the basis of a jurisdictional needs assessment or for whole populations within a specified region. As can be seen from Table 3, individual care for specific populations is commissioned in the US. At the subpopulation level, services have been commissioned for people with specific needs such as children, or specific services such as mental health, services for older people or those with long-term conditions, health and social care, chronic disease, and services to reduce health inequalities. Services purchased for populations include dental, pharmacy and GP services.

Table 3.  Services commissioned at individual, subpopulation and population level

There was very limited evidence to assess the impact of commissioning on service use, outcomes or value. Of the seven relevant studies related to commissioning at individual, group and population level (Dusheiko et al. 2006; Freeman and Peck 2006; Goldman 2010; Salmon et al. 2012; Barnes et al. 2013; Ly and Glied 2014; McLeod et al. 2015), three studies described impacts on health service use, one on outcomes, one on quality and two on value for money.

With respect to service use, Barnes et al. (2013) found that in the context of inappropriate treatment of routine childhood conditions, service redesign led to reductions in emergency admissions for children. A study of joint commissioning for health and social care services demonstrated no change in length of stay, reduced hospitalisation or delay in transfer of care (Goldman 2010). A third study of fund-holding practices demonstrated reduced emergency and elective admissions (Dusheiko et al. 2006).

One study of joint health and social care commissioning demonstrated improved quality of care as perceived by users and carers for patients with mental illness (Freeman and Peck 2006). One study, a randomised trial as part of PCT commissioning, demonstrated improvements in smoking rates (McLeod et al. 2015). Two US studies involved analysis of economic benefit. A study of US managed care reported improved physician incomes and time with patients but little overall improvement in value (Ly and Glied 2014). A study of accountable care in three practices showed reduced costs and improved quality of care (Salmon et al. 2012).

There were a limited number of studies exploring the facilitators and barriers to commissioning. Successful commissioning relies on detailed knowledge of service and sector as well as information sharing and networking (Checkland et al. 2012). Identified barriers include lack of resources (Bradley et al. 2006), time and personnel; difficulties associated with maintaining relationships with partners (Checkland et al. 2009) and obtaining external support (Naylor and Goodwin 2011); and limited use of decision support tools (Marks et al. 2011). Attitudes vary on the extent to which GP commissioning is likely to deliver population benefits (Gridley et al. 2012; Perkins et al. 2014), especially with respect to reducing inequalities (Turner et al. 2013).

In Australia, commissioning has been used largely to fill gaps in primary healthcare service delivery for individuals and subpopulations rather than as a framework for mainstream health services. For individuals, services not included in Medicare, such as home care (Veterans’ Home Care) and disability care (National Disability Insurance Scheme) have been commissioned. For subgroups, commissioning has focused on conditions where there is a problem of access to high-quality specialist care – for example, for people with severe mental illness or diabetes, or those in palliative care. For populations, commissioning has tended to centre on groups not otherwise adequately served – in particular, rural areas or Indigenous populations. There is little experience with commissioning mainstream primary health care and little published literature from Australian programs other than from Coordinated Care Trials in the 1990s and evaluations of existing programs, such as the After Hours Other Medical Practitioners program.

Internationally, the evidence base for the impact of commissioning was weak. Most studies examined commissioning for populations; few explored commissioning for subpopulation groups or for individuals. There was insufficient evidence to identify any preferred form of commissioning. Although planning, contracting and monitoring are all critical elements in the process of commissioning, the emphasis of studies is on planning, with some attention to contracting but very little on monitoring contracts and performance, or supporting patient choice. The lack of emphasis on monitoring and evaluation may reflect the relatively early stage of development of commissioning.

Grey literature reports cite lack of skills and capacity as major barriers to the implementation of commissioning. Skills are especially important in the securing or contracting domain for procurement, risk and contract management (Figueras et al. 2005). Local commissioners and providers need to have the competency for local decision management (Russell et al. 2013). This includes priority setting, engagement of the population and stakeholders, quantifying, costing, structuring demand and ensuring services are effective and high quality. Collaboration and partnership, information management, innovation, governance, compliance, accountability, project management and leadership are key (Dickinson 2015). There need to be measures in place to ensure stability of the management workforce as high staff turnover undermines the relationship (Newman et al. 2012). This implies significant investment in developing skills in the workforce to be involved in the commissioning process and support (resources and advice) for members in the field.

Successful commissioning also requires a clear policy framework of national and regional priorities that define agreed targets for commissioning agencies. Most countries appear to be moving away from a strict competitive model in which there is a distance between purchaser and provider as this runs counter to many models of integrated care and provides little real benefit in terms of lower pricing of services.

The European Observatory report ‘Purchasing to improve health’ (Figueras et al. 2005) found that engagement of consumers and providers, especially physicians, is considered to be critically important but has proven difficult to sustain. Providers need autonomy to respond flexibly to contracts (Figueras et al. 2005). Much of the backlash against managed care was a result of perceived restrictions on the care that could be provided. Commissioners need the flexibility to be able to respond to patient needs and changing conditions, and to develop innovative solutions. Strict interpretation of competition law in New Zealand made it difficult to develop the long-term contracts and relationships between purchasers and providers that are necessary for effective commissioning and service continuity (Ashton et al. 2004). Integrated care involving primary and secondary care or health and social care is especially difficult to deliver in the context of competition and separation of purchaser and provider (Mannion 2008). Commissioning for long-term condition services requires competition and purchasing policy that allows commissioning to be undertaken in partnership with providers, blurring the distinction between commissioners and providers (Shaw et al. 2013).

Both providers and consumers need to be informed and have an opportunity to provide input into the commissioning process (Joyce 2015). This takes time but is crucial in building trust and legitimacy for commissioning, especially where difficult decisions have to be made (Dickinson et al. 2013). It needs to be clearly driven by policy mandating clinician and consumer involvement in the commissioning process (Sampson et al. 2012).

In the countries studied, policy and governance settings are usually defined by government and professional bodies that have broad stewardship over the health system. These define the broader context in which commissioning occurs, including workforce supply, professional standards, funding and incentives as well as regulating the scope of services that can be commissioned for each subgroup of people (Figueras et al. 2005). Governments may also define the models of care or healthcare package, including the structure, quality, amount and cost of services. There is usually some restriction of access to services to remain within budget (Mannion 2008). For individual commissioning, this implies some degree of patient enrolment or registration. Excessive gatekeeping that restricts provider autonomy or choice of preferred providers was found to be counterproductive in the US (Ham 2008). More recent models, such as accountable care organisations, have involved a greater choice being offered to providers and patients (Robinson 2004).

It is also important that there is not high variability in uptake of the program by providers, as occurred in UK GP-holding in the 1990s, as this is likely to lead to inequities (Mannion 2008). This needs to be addressed through widespread efforts to engage providers, to monitor uptake both geographically and socio-economically, and to monitor any consequent inequities of access to quality care that may arise.

Adequate information on the cost, volume and quality of healthcare services is critically important for setting priorities, contracting and monitoring performance. Lack of information resulted in serious problems in New Zealand in the 1990s (Ham 2008); these have been partly addressed with the introduction of the Primary Care Strategy in 2001 (King 2001) and subsequent developments. There needs to be clarity of roles and responsibilities and supportive legal frameworks for commissioning. This is particularly important in the context of funds pooling or flexible use of budgets and joint commissioning involving different levels of government or sectors (Newman et al. 2012).

There is a need for high-quality nationally standardised performance measures and data requirements to be built into contracts, alongside ongoing monitoring and evaluation. This should be reinforced by public reporting, and incentives to reward providers and consumers for good quality of care, as part of ‘value-based purchasing’ (Guterman et al. 2013). A poor fit between goals and intended outcomes and performance measures may lead to unintended consequences (e.g. sacrificing quality over cost saving).

Little evidence of the effectiveness of commissioning at any one level (population, subgroup or individual patient) is available and observed impacts are highly context-dependent. This review suggests that there is significant work to be done in areas of policy and governance, funding systems and incentives, patient enrolment or registration, information systems, individual and organisational capacity, community engagement and experience in commissioning. Australia might be wise to start commissioning in areas where the benefits are clearest, monitoring progress carefully and only expanding as experience is gained and all the elements required are in place.

None declared.