HEALTH CARE COMMISSIONING IN THE ENGLISH NHS: EVIDENCE, CO-PRODUCTION AND QUALITY OF DECISIONS

Purpose: In England, local NHS commissioners plan, fund and review health services ranging from emergency to community-based care for a defined population. We aimed to investigate use of evidence, extent of co-production (collaboration and interaction between players in commissioning decisions) and factors associated with self-rated quality of decisions by local commissioners of health services.

Method: Cross sectional survey of decision making quality by a random sample of commissioners in England stratified to reflect population size and level of deprivation. Measures used: three measures of evidence/information use and influence - two previously validated, one designed de novo; two measures of quality of decisions - the Decisional Conflict Scale and the COMRADE scale (both adapted for use for organizational-level decision-making); one measure of co-production developed de novo. Demographic and job role data were collected alongside characteristics of the commissioning organization.  Analysis was undertaken using backwards, stepwise, multiple linear regression.

Result: Two hundred and eighty commissioners from 11 representative organizations in England responded (77% response; 63% complete surveys).  Twenty three per cent considered “available budget/cost savings” as the most influential factor on commissioning decisions with “evidence of effectiveness” the second most influential factor (11%). Regression analysis suggested that both perceived influence of evidence (of safety/quality, effectiveness and cost-effectiveness) and overall levels of co-production were associated with perceived decision quality. These factors in combination explained 14% of the variation in decision satisfaction. (Influence of evidence (standardised beta=0.24); co-production (standardised beta=0.21)).

Conclusion: Organizational decision making to plan services, and the uses of evidence are important in all health care systems. Perceived quality of commissioning decision-making for our respondents appeared to be affected both by extent of co-production and by the influence of evidence. We found no appropriate definitive measures of quality of decision making and used adapted individual clinical level decision quality tools. Large changes are planned in the English NHS, groups of family physicians are soon to take over running much of the budget (£65bn (62%)). They will need enhanced understanding of commissioning, decision making and evidence. A squeeze in real terms is predicted and difficult decisions will be needed. The process is complex and our results suggest that that there will be important lessons for these new commissioners to learn.