21.03.14
Commissioning now and in the future
Source: National Health Executive Mar/Apr 2014
Across most areas of the NHS there are calls for change, and commissioning is no different. David Stevenson reports
on how commissioning may develop in the future.
Speaking at the recent Health and Care Innovation Expo 2014, Dr Jason Broch, GP and clinical chair, NHS Leeds North Clinical Commissioning Group (CCG), asked a simple question – what is commissioning?
People give far more answers than might be expected, depending on their medical background.
“It is a very complicated idea,” he said. “But for me, to keep it simple, and especially when talking to patients, we say it is pots of money that have come from the government and we need to buy services from healthcare providers, social care providers and general practice to try to get the best healthcare outcomes for individual patients, who we are responsible for commissioning on behalf of.”
Fragmented
But fragmented commissioning is a major problem, with services bought from various sources that don’t necessarily integrate or communicate. “Yet, as commissioners we stand back and expect the system to work together, even though it has all been bought and put together in a very fragmented way,” he said. “Things can be improved.”
Funding for commissioning has become even more fragmented since the CCG structure came in.
But despite the reforms and the challenges, Dr Broch said that the increased amount of clinical leadership in commissions offers “real opportunity”. He added: “Ironically, the fragmentation of the budgets, from my perspective, has also been a bit of a strength because all of a sudden people have realised they can’t do it all on their own. They have to work together for common goals.”
Future commissioning
Rosamond Roughton, national director for commissioning development at NHS England, discussed the key financial documents published in December – CCG Resource Allocations, the NHS Planning Guidance, the NHS Standard Contract and the 2014/15 National Tariff Payment System.
The CCG allocations allotted £200bn to commissioners across England to spend on care for 55 million people over two years.
She said: “The development of excellent commissioning is a fundamental part of having an NHS free at the point of use, available to all, not just for people now but for people in future generations.”
She sees two big drivers at play in the development of commissioning: “Firstly, we are in the middle of a very big shift in the balance of relationships between individuals, communities and the state. That applies to public services, or public-funded services, everywhere. This has big implications and provides big opportunities too.
“The second driver is the financial crisis. The health service – like every other public sector department – faces unprecedented challenges. So, the decisions that commissioners have about investment or disinvestment really matter.”
But what do the drivers mean, exactly? Roughton thinks they will change commissioning in four key ways, making it more:
• Information-based: The way that intelligence is being used to shape decisions – not just about investment but also about the way that people can act immediately and make real changes happen.
• Outcomes-based: Moving towards something that has a longer-term goal, with a more appropriate spread of risk and mechanisms to support it.
• Place-based: One of the three big factors the World Economic Forum identified in how societies across the world can enable sustainable healthcare systems. This could drive the country towards greater joint and shared commissioning across CCGs and between NHS England.
• Asset-based: How commissioners will revisit their relationship with the public as stewards of public resources.
“One final hope is that there will be clinical leadership in commissioning. In the last two years we have made some great strides and there has been a great alliance between fantastic clinical leadership and high-quality professional support – both in-house and delivered at scale,” she said. “I really hope that is something we can sustain in the coming years.”
Benefits and value
Gwyn Bevan, professor of policy analysis at LSE, also focused on information-based commissioning.
“The problems faced in commissioning,” he said, “are that it is difficult to come up with ways to develop a common sense approach for commissioning services as you have to assess what patterns look like across a care pathway.”
Three vital bits of information are needed before an intervention can or should be made. These are: knowing what it costs; how the treatment is given; and what the benefits are. But typically healthcare system focus more on costs and activity than benefits.
He added: “We have been able to design a model that allows people to estimate the benefit and value of services. However, it is vital to not just involve healthcare professionals and commissioners in the process, but members of the public as well.”
Professor Bevan added that having the public on board, especially when making interventions or commissioning services, is imperative. Patients also need to see clear benefits if they are not to reflexively oppose changes to services, too.
Compassion
Hilary Garratt, director of nursing, commissioning and health improvement at NHS England, rounded the seminar off by saying that as well as having the right services in place, we must have a caring system in place also.
“[We] need to develop a culture of compassionate care as commissioners, and to do this it is important to connect with our values, which helps us connect with others in delivering the best service,” she concluded.