Design In Practice

The research project has investigated the Practice Based Commissioning (PBC) framework focusing on the North West of England. Our work has been conducted, in particular, at three main levels:

1. NW Strategic Health Authority, where we examined how PBC has been implemented with a focus on the diversity of models of governance, support and collaboration;
2. PBC groups: three case studies of how PBC groups re-design care pathways in practice, mapping examples of their service redesign and commissioning processes;
3. Medical Practice level, case study of one large GP practice, investigating how clinicians re-design services as part of their daily activities, through participating in their meetings and conducting interviews and short design interventions.

Through these investigations, interpreting PBC activities as a co-design process, the team sought to understand if and how design, and other creative methods and tools drawn from design, could support commissioners’ activities to provide a deeper understanding of the applicability of ‘design thinking’ as a means of facilitating innovation, and developing interdisciplinary methods of participatory design.

Key issues related to PBC, highlighted by this project include:

a) difficulties associated with relationships between PCTs and PBC such as: lack of clarity over roles and responsibilities of PBC within PCTs; mistrust between hospital managers (particularly financial managers) and GPs; perceptions of poor support from PCTs and excessive bureaucracy associated with PBC business cases; poor data provision impeding development of  commissioning projects;  

b) difficulties associated with lack of motivation and engagement of ‘rank and file’ GPs in PBC such as: lack of realistic and effective incentives to motivate clinicians to become involved in PBC; a perception that time devoted to PBC is not adequately rewarded through PBC frameworks; concerns related to practice workload and continuity of care for patients; lack of confidence in ability to analyse data and produce business cases

c) difficulties associated with articulating a common local vision for healthcare which can result from conflicts of interest between PBC groups, PCTs representing primary care and the secondary care or Foundation Trust system

PBC has initiated a cultural shift toward a more collaborative, integrated and community centred commissioning of care, but it will need significant infrastructural changes and further experimentation to reduce barriers to collaboration, enhance integration of provision and properly engage with the public. To support this transformation, design can supply tools and methods developed in co-design and transformation design projects.

It is proposed that, instead of focusing exclusively on GP responsibility for commissioning, the focus should be on the broader communities that could be involved in commissioning (communities of co-creation) as an integral part of the consortia or federations, and not only as a point of reference for individual projects. In addition the narrow focus on redesign of individual disease pathways might profit from an expanded approach involving development of a wider ‘scenario for change’ that considers health and wellbeing at its centre. A shift from a ‘GP centred commissioning’ to ‘community centred commissioning’ recognises the key role of GP consortia as facilitators (together with local authorities) of commissioning networks, but focuses on co-creation as main strategy for service innovation.