This week's blog is by one of the directors in our health consulting business, who is currently on secondment to Australia, building her knowledge and experience of other health care systems and hoping to take the best practice from the UK to support Australia to deliver sustainable, high quality health services, and to bring their good ideas back here.
I remember the moment I made the decision to move into commissioning nearly 10 years ago. At the time I was managing a general surgery department and the surgeons and I, along with the other general surgery providers in the area, had been invited to a meeting to talk about the implementation of the national Improving Outcomes Guidance (IOG) for Upper Gastro Intestinal (GI) cancer.
The lead commissioner for cancer for the area set out what the IOG said about how Upper GI cancer services should be delivered, including the need for providers who could offer a 24/7 rota, better coordination across providers with shared Multi-Disciplinary Teams (MDTs),centralised services for rarer cancers and ceasing of occasional practice.
Cue much muttering amongst the providers:
- "a shared MDT would be rather inconvenient for us all, we'd have to move our theatre lists around"
- "our surgeon who only operates on a few Upper GI patients a year is retiring in a few years, let's just leave things as they are until then"
- "our service is fine as it is, we meet the standards, we're fine".
The commissioner's response brokered no argument "the guidance is based on evidence, we know if we implement it, fewer patients will die. Our outcomes are currently nowhere near the best in the country and this is a shared problem and responsibility for us all. We're going to make these changes now, and we're not leaving the room until we've agreed how we're going to do it".
She had the clear authority of a decision maker, and we were all thoroughly put in our place. A totally different conversation then ensued focussed on how we might work together to make implementation possible. After that I knew that being a commissioner like her was what I wanted to do. I believed that commissioning provided a unique opportunity to make a real impact for patients. Within six months I was working for that same commissioner.
One of the first things I learned when I began commissioning was the commissioning cycle (Figure 1). At its highest level, good commissioning requires strategic planning, procurement of services, and monitoring and evaluation; building on each other in a continuous cycle.
Figure 1: The Commissioning Cycle
Commissioning Cycle, NHS. See also: http://commissioning.libraryservices.nhs.uk/commissioning-cycle, 7th June 2016.
I started to pick up the skills needed to implement this cycle:
- working with public health doctors to understand population health needs and disease prevalence in the areas I was responsible for
- learning how to set standards and work with clinicians to develop evidence based and outcomes focused policies and service specifications
- prioritising investment and disinvestment
- consulting with patients and the public around changing local services
- running procurements and service reviews
- negotiating contracts and incentives
- monitoring performance to determine what had been achieved and deciding how we might achieve more in the future.
Commissioning seemed to work – each year we took decisions on how to offset demand growth with efficiency improvements elsewhere, while balancing our budget. The providers in our area were financially stable, and outcomes appeared to be improving (including in Upper GI Cancer).
However, much has changed since then, including the reorganisation of commissioning structures and much greater pressure on budgets everywhere. More recently, the concept of 'commissioning' appears to have fallen out of favour. The commissioning cycle is rarely referenced, I've seen it mentioned only once by NHS England (in their 2014 guidance on commissioning for effective service transformation1) and I've heard numerous colleagues within and outside the NHS suggest that commissioners are no longer needed, and providers should be left to get on with improving services themselves.
Recent developments also suggest that commissioning is being seen as less important within the system. For example, a number of the Primary and Acute Care Systems (PACS) vanguards are moving in the direction of less distinct commissioning, with the set-up of Accountable Care Organisations (ACOs) that merge commissioner and provider functions (what is not yet clear is which functions would be reserved by any residual commissioning organisation). Last month Simon Stevens appeared to further support a blurring of the boundaries between commissioning and provision in a Health Service Journal (HSJ) interview, backing the 'pooling of sovereignty' to implement Strategic Transformation Plans (STPs), with providers and commissioners merging into the equivalent of combined authorities to push through the changes that are required.2
Whilst a move to more collaborative working can only be beneficial for the NHS, the loss of commissioning sovereignty concerns me – how can we be certain that service changes offer the best outcomes and value for patients, when the only organisation statutorily responsible for ensuring this, is no longer the decision maker? There may be a strong incentive on local providers to prioritise investment based on their needs, rather than the needs of their populations, and to award new contracts to themselves, rather than the most capable provider. In the short-term this might meet the immediate priority of financial sustainability of providers, but in the longer term it risks delivering less value, a less accountable healthcare system and impacting the financial sustainability of local health economies.
The lack of any clear decision maker is also concerning - STPs have already identified 'veto power' of individual organisations as a barrier to progress – the proposed response (according to the same HSJ interview with Simon Stevens)3 is for national leaders to 'call it' on difficult decisions about service reconfiguration. This would normally be the decision of the relevant commissioner.
The commissioning system is far from perfect, but in my view a credible alternative has yet to be put forward which ensures that services are developed based on the needs of the local population and which offers maximum value to patients and taxpayers alike. If I think back to the commissioner who challenged myself and my colleagues on our willingness to change upper GI services, I can't help but wonder whether this sort of challenge and accountability will be achieved in the future.
1 Commissioning for Effective Service Transformation: What we have learnt, NHS England, 2014. See also: https://www.england.nhs.uk/wp-content/uploads/2014/03/serv-trans-guide.pdf
2 Exclusive: Stevens floats 'combined authorities' for the NHS, HSJ, 19 May 2016. See also: http://www.hsj.co.uk/sectors/commissioning/exclusive-stevens-floats-combined-authorities-for-the-nhs/7004897.article
3 Exclusive: Stevens floats 'combined authorities' for the NHS, HSJ, 19 May 2016. See also: http://www.hsj.co.uk/sectors/commissioning/exclusive-stevens-floats-combined-authorities-for-the-nhs/7004897.article
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