Commissioning in context: a view from Bristol

Commissioning sustainable, patient-centred cancer support services like the Recovery Package can feel tough. Here a commissioner in Bristol shares their experience in the hope of helping and learning from others.

If there’s one thing I’ve picked up from other people’s blogs it’s that you need a good opening line to lure people in. I’m not sure an introduction is gripping enough in 2017 but I liked the 80’s... I’m Emma. I’m a Macmillan professional working at Bristol Clinical Commissioning Group (CCG) to implement our Living Well With and Beyond Cancer Strategy. Commissioning (which was described to me as a dark art when I started) is changing fast at the moment. I don’t know about you, but commissioning sustainable, patient-centred cancer support services feels like a real challenge.

As a way of sharing (and as a form of therapy), I’ll be blogging once a month to reflect on our learning in Bristol and to share ideas, reading suggestions and documents as we develop them. I’m hoping it will be a platform for a conversation for those of us who are trying to get our heads around how we can better deliver support for people to live well with and beyond cancer. This will be a warts and all account, not a ‘guide to…’. Other Recovery Package guides exist. Nor is it a ‘how to’ – we all need to find our way with this that fits our local contexts. Instead this blog is my contribution to us all sharing, thinking and being open about how we are all doing on this.

In the first instalment below I’m setting the scene. Over coming months I’ll take topics such as evaluation, commissioning levers and building networks and describe where we’re coming from locally and the steps we’re taking to affect change. Here goes.

Part 1: Driving change - a backseat view (September 2017)

The context in Bristol

In Bristol, like in many places, lots of work has been done by passionate, committed people to improve support to people so they can live well with and beyond cancer. Both of our Trusts are doing well in terms of stratified follow-up for breast, colorectal and prostate cancers. North Bristol NHS Trust was involved in the National Cancer Survivorship Initiative pilot and University Hospitals Bristol NHS Foundation Trust has just completed a local CQUIN to design new follow-up pathways.

We have five support workers and many Clinical Nurse Specialists carrying out Holistic Needs Assessments (HNAs), signposting, running health and well-being events and offering 1:1 support. Bristol CCG is using a local tariff and block contract to pay for recovery package activity. Macmillan is supporting local pilots for community based OT rehab workers, services to provide treatment support, fatigue management and pre-habilitation support. Local charities such as Penny Brohn and The Harbour are supporting people holistically and several health and well-being/self-management days and courses are on offer, both within the NHS and the voluntary sector.

Breathe. Lots.

However, it is still very much a work in progress. At the moment, you could say that support is delivered within our institutional boundaries. The type of support somebody might get depends on their cancer, the staff they meet, the Trust providing their treatment and, it is very hospital based.

Bristol’s Living Well With and Beyond Cancer (LWWBC) Strategy

Bristol’s Living Well With and Beyond Cancer (LWWBC) Strategy tries to address this by setting out how we can support all people affected by cancer to say 'I am living as well as I can with/beyond my cancer' by feeling ready for treatment, as well as possible and in control. It also sets out how Bristol can support carers, volunteers and staff so they have the resources they need. It was based on some brilliant literature reviews (download the literature review [PDF]) and engagement events (download the event presentation [PDF]) that were done before my time. 

A reality check

The LWWBC strategy was written in 2015. A time before STPs, Cancer Alliances, current financial constraints, primary care commissioning moving to CCG responsibility or change in our CCG leadership and commissioning footprint.

It’s an obvious point to make but these changes, particularly the financial pressures and new STP footprints, have huge consequences for how commissioners behave and therefore how we affect change. What better time to try and do things differently? Outcomes based commissioning, new models of care, accountable care organisations – living well with and beyond cancer services could make use of them all. But trying to re-design a service whilst commissioning itself is being re-designed feels like trying to drive change along a jelly-like road.

I’m starting here as I think it’s worth holding a mirror up to the context we are working within and acknowledging what is within our control and influence and, possibly more importantly, what isn’t.

In response to these realities, I’ve started to focus on a few areas, cost benefit analysis, developing our community of practice and self-preservation.

Cost benefit analysis of our LWWBC services

As I’ve said, we have a lot going on in Bristol under the banner of LWWBC. But that doesn’t mean we know what and how to commission for the future. With the help of Macmillan, we are working with health economists to pick apart what we are the costs of providing cancer support services, and who pays and what the benefits of our services are and who feels them. With this information, and through a series of participatory workshops, we’re aiming to develop our new and costed model for living well with and beyond cancer.

Community of practice

I’m recognising value in using my role to bring people together from across the system and how much it motivates us along the way. An expanding group of nurses, physios, OTs, managers, patients, support workers and psychologists have met to discuss elements of the strategy. Local Macmillan colleagues have supported us with croissants and a space. Unanimously positive feedback is the opportunity to meet other professionals from across the system. If things are this complex, change will inevitably be chaotic. Maybe a conversation between a psychologist and OT will have much more impact on our LWWBC agenda than my sparkling service specification. That’s sometimes a difficult thing to accept. In part because it makes the change so intangible and unpredictable and in part because it highlights the need to let go a little.

Self-preservation

Finally, trying to implement a change is always a challenge. There are lots of people outside of the CCG that I’m working with and I am seeing myself as part of a virtual team or, our community of practice, as I’ve said above. However, it feels important to mention that at times this feels a little lonely. There is support out there though. The School for Change Agents, run by The Edge, is a free recorded course for anybody trying to affect change in health and care, designed to support you to ‘rock the boat while trying to remain in it’. I’m also finding being part of a Macmillan community is very motivating, there is a lot on offer, the System Redesign work, Connecting the Dots for Commissioners, regional education peer support events and professional coaching are all giving me confidence to rock our boat.

Each month I’m going to challenge myself to share one lesson. This month it’s this, I am valuing more and more the importance of understanding where we are each coming from and setting our destination together before embarking on the journey.