This blog by Professor David Colin-Thomé, PCC chair, considers what is next for commissioning. The need to focus on value-based outcomes, population need and prevention, shifting from a contractual culture to one of enablement and a transparent accountability. There is a need to move beyond collaboration to partnerships, radically changing how services are commissioned and enabling innovation in delivery.
David Colin-Thomé
I am a long-time critic of NHS commissioning, having little advanced from its purchaser origins- with the perennial caveat, there are honourable exceptions. A potted history of its origins is necessary, in my case a living memory! The 1990 NHS and Community Care Act introduced by the Thatcher government defined an “internal market”, whereby health authorities ceased to run hospitals but “purchased” care from their own or other authorities’ hospitals. Certain GPs became “fund holders” and were able to purchase care for their patients. I, despite my different political leaning, became a very committed fundholder, as the saying went- a GP with a budget is worth 10 on a committee. So, it proved. The subsequent Blair government removed most of the NHS ‘market’, retained the concept of a separation from providers but the more emollient phrase commissioning ensued.
My gripe with commissioners is their role should also be much more of an enabler and shaper of the NHS system rather than the bureaucratic contractual process it focuses on. And despite the huge commissioning bureaucracy, what has been achieved? We still lag our western European countries in key clinical outcomes – improvements in the Blair government years led by clinical ‘czars’ but deterioration since. Persistent scandals in care of the elderly and now maternity services, and widespread failure to utilise the personal medical services (PMS) contract imaginatively to advance general practice. And more fundamentally why a Care Quality Commission if there was effective commissioning of providers?
Commissioning is necessary but not as it is. And Secretary of State Streeting’s 10 Year Health Plan, the most radical of all the NHS reforming plans, is inter alia reshaping and indeed reinventing commissioning. NHS England to be abolished, integrated care boards (ICBs) slimmed down, and local ‘operational’ commissioners removed. The refocus is on providers and communities with the centre piece being neighbourhoods. Commissioning will be strategic – from fragmented activity purchasing towards hopefully value based outcomes, population need and prevention. And necessarily from a stultifying contractual culture to one of enablement and a transparent accountability. There is fresh talk of collaboration but is often a ‘lip service’ word. I prefer partnerships with supportive open governance far removed from the governance of control and compliance- a current governance that appears mistrustful of clinicians and a bypassing of primary care.
So where now? I am involved with other mentors in the development of some neighbourhoods who did not make the national support scheme – which sadly itself appeared more directive that developmental. We are currently encouraging the neighbourhoods to work in partnership with their ICB to respond to the recent letter from Jim Mackey, for two remaining years CEO of NHS England. If the ICB accepts the partnership offer, and currently seemingly exhibiting little senior interest in a key part of government policy, it’s a win-win. The ICB fulfilling its new role and the neighbourhood possessing continuing agency-important if the promised inversion of influence within the 10 Year Health Plan is to be achieved. To briefly refresh; From hospital to community. From sickness to prevention. Analogue to digital. All maximally achievable within neighbourhoods with the power of local communities, the prime role of community based services and population based general practice.
A new significant role beckons for strategic commissioners if they aspire to be less operational. Quintessentially sense making, enabling, supportive and dare I say it, inspiringly proactive. An authentic system leadership role as equal experts with providers and a fresh approach to contracts. Contracts are necessary but should underpin relationships, not define them.
I will repeat some thoughts, I hope not too forlornly, how the present contract culture can be liberalised. Maybe the clue is in the name, not buying quantity and forcing quality but commissioning high value care for patients with value defined as the health outcomes achieved for money spent. Commissioning should entail enabling providers who possess almost exclusively the clinical knowledge, to set their own quality and performance indicators against which they will hold them to account. It would be naïve to think all providers will without hesitation set high and stretching indicators, necessitating all provider quality offers to be in the public domain to encourage ambition. If an unofficial cartel of low quality offers emerge, publicise it and then transparently rigorously apply any national quality indicators. Enabling and then holding to account is paramount and public involvement and feedback mandatory.
Commissioners as the people’s organisation. To this end PCCs support of and my involvement in Community Oriented Integrated Networks (COIN) involving the public as partners is very much of this new world.
NHS policy promulgates organisations working in systems thereby adding value to their solo working. A novel challenge for commissioners as the NHS comes to terms with a policy shift from its classic nationalisation culture and individual hospital centric past. Not only how can PCNs be commissioned and neighbourhoods supported but importantly how to commission local enablement for the individual patient who currently has little influence and choice? Complex issues can only optimally be addressed locally. For the individual patient the NHS has much to learn from local government that focuses much more on the individual citizen.
To summarise- transparent partnerships beyond collaboration must be the future to deliver on the most positively radical NHS reform ever.
Professor David Colin-Thomé is chair of PCC. PCC supports primary care providers and commissioners for more information contact enquiries@pcc-cic.org.uk or visit www.pcc-cic.org.uk.
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