Public health medicine - developing effective and fair funding policies

Dr C is a consultant in public health medicine. Here he reflects on developing effective and fair policies with CCGs for funding.

What's the issue you reflected on?

Tell us about an incident/situation/feeling that gave you cause for reflection

I work in health care Public Health and support the local clinical commissioning groups (CCGs) in their priority setting process including commissioning policy development.

As a local health system we were updating the commissioning statement for septorhinoplasty; especially under what circumstances it will be funded. Local ENT consultants wanted further indications to be included so that septorhinoplasty could be funded for these patients.

I found it was hard to define the boundary between clinical need (where there is definite clinical benefit) and cosmetic intervention. The ENT consultants were trying to do their best for their patients by including indications such as severe anosmia and recurrent epistaxis.

As a Public Health consultant I need to consider the cost of performing these interventions on patients who might gain marginal benefit. I did my best to work with CCG GPs and the local ENT consultants to agree a consensus.

What made you stop and think?

I wondered what the appropriate approach to take was in finalising the funding indications for septorhinoplasty. Should I be looking at the best available evidence?

I often find that the evidence is not available at the level I am looking for. It also becomes hard to disagree with the local experts and I need to avoid giving an impression that this is purely a cost cutting measure.

There are many ways to reflect - how did you do it?

I went over the scenario many times and debated with myself what a rational person will do. I also discussed this with one of my trainees to gauge their views.

I challenged myself to defend my course of action, and the indications that I was intending to include/exclude. I thought about the possible reaction of the local ENT consultants, the CCG GPs and the managers.

I thought through the impact the revised statement will have on the patients and the resource implications for the local commissioning arm of the NHS.

What did you do?

Tell us what you took away or learned from this experience?

Evidence may not always be the answer in formulating commissioning policies as it may not be available. Hence local consensus has to be reached working closely with primary and secondary care clinicians.

When there is disagreement between the two it takes a lot of time and effort to agree a common position. The purchaser provider split sometimes could hinder clinical collaboration and cooperation and I need to work around this potential barrier.

Taking the process through established mechanisms in the local health system at times can be cumbersome and frustrating - plenty of time is needed.

How did it change your thinking or practice?

I will start a dialogue with the respective specialists and will involve the lead GP from the CCG. However this may not always be possible due to time constraints. But I will endeavour to adopt this approach.

Unless there is local buy in from secondary care specialists in commissioning policy development, it is almost impossible to implement these locally.

What have been the effects of your changes?

Has it improved your practice and outcomes?

This needs to be seen. I hope that the new approach will lead to better engagement and commissioning policies that are agreeable to local clinicians.

Many commissioning policies are coming up for review and I will be adopting this approach. A well-developed policy with local clinician engagement and approval will benefit patients in the greatest need and avoid the opportunity cost of treating patients who are unlikely to benefit from an invasive intervention.

Has it affected others?

Yes. The revised policy will make the intervention available to wider groups of patients. Procedures will be offered to patients quicker as the clinicians are clear what is being commissioned and which patients they can operate on.

This will also help if the local commissioning organisation decides to introduce prior approval for procedures as the criteria is clearer and has the agreement of local clinicians.

Top tips

What top tips would you give to doctors in your specialty about how to get the most from reflection or thinking constructively about a particular problem?

  • If you feel something has gone particularly well then it is worthy of reflection to identify actions, approach or areas to copy for future work.
  • Similarly if something has gone badly this is certainly worthy of the investment in time and effort to learn from it so that there is less of chance of this happening again.
  • Keep an open mind and try not to blame someone else or yourself for that matter.
  • The objective is to learn and improve on an ongoing basis.
  • As far as possible write some brief reflective notes as soon as possible.
  • Always use a selection of reflective notes during your appraisal and discuss these with your appraiser.

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