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Commissioning sustainable change: shaping the NHS for the future

American author Marilyn Ferguson once observed that: “It’s not so much that we're afraid of change or so in love with the old ways, but it's that place in between that we fear… It's like being between trapezes.” In many ways, the NHS is between trapezes, says Julia R A Taylor, No Delays priority programme director at the NHS Institute for Innovation & Improvement

From old monolithic structures to the new plural market; between the patient as passive recipient of care and a world of choice; between the old models of provider and activity driven care to one that is based on outcomes and pathways.

For commissioners, these and other changes present tangible opportunities to influence the pace of change and the future shape service provision and delivery in the NHS. Effective commissioning is crucial to achieving high quality, responsive and cost effective care within the developing NHS economy. It plays a vital role in satisfying both local needs and in delivering key national objectives. For instance, from a commissioner’s point of view, the delivery of 18 weeks should be a transformational goal that not only brings the benefit of reducing waits, but also provides the chance to reshape local services based on actual patient need.

All very easy in abstract, but as anyone working in the NHS knows, the urge to jump to solutions can solve problems in the short term but can generate headaches for the long term. When the NHS Institute’s No Delays programme was instigated in 2005, the task was to support hospitals in approaching 18 weeks in a way that put sustainable service improvement and redesign at its heart and help them as much as possible be in a position to avoid the more short term approaches to tackling waiting lists.

And now, just as many providers have embraced 18 weeks as an opportunity for service transformation, so too commissioners are finding that the obligations and opportunities of 18 weeks mean that they are shifting their focus away from purchasing activity and stages of treatment to understanding the entire patient pathway in a way that reaches beyond December 2008.

One of the perennial myths in the NHS is that demand always exceeds capacity. However, if that was the case, waiting lists would continue to rise without control whereas they are largely either stable or falling. As healthcare experts Kate Silvester and Paul Walley have found: ‘Our analysis indicates most queues within the NHS are relatively stable, suggesting that capacity and demand variation are the cause.’ In other words, there is enough capacity. It is just that we need to match it more accurately with the demand and improve the processes that form part of the patient journeys to make the system flow better.

So, what can commissioners do in a practical way to influence patient pathways? It’s a difficult balancing act: being able to lead – and where necessary, enforce – sustained performance, without removing providers’ ownership and responsibility. The No Delays programme believes that its tools can help with this – both the No Delays Achiever that uses trusts’ own data returns to compare provider status and help decide priorities for service redesign and in shaping supply, and also Commissioning for Patient Pathways with its unique commissioning matrix that enables a structured approach to commissioning planned care pathways across organisational boundaries.

But, of course, commissioning sustainable change is larger than one set of solutions or tools, and if commissioners are to be world class they will need not only the ability to drive change themselves but also the capability to nurture it in their partner organisations so that it is self sustaining across the health economy. There will always be a certain amount of performance management and leverage through procurement in this process, but it is also about better assessment and planning, courage to use new ways of working, a devotion to relationship management, and always an eye on that most important trapeze bar to catch - the outcome for the patient.

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