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The concepts of ‘contracting’, ‘purchasing’ and ‘commissioning’ were introduced into the NHS in the late ‘80s and early ‘90’s.
From a service based on need and which provided care without too much emphasis on cost, the introduction of business management concepts turned the National Health Service into a “market” with a “purchaser-provider” split - the intention being to encourage competition among providers, reduce cost to HM Treasury and improve quality and responsiveness.
In 1991, health authorities and GP “fundholders” became the gatekeepers to all purchasing but it was only in the late 1990’s that the NHS adopted primary care led “commissioning” as a more sophisticated and strategic activity - one that encompasses assessment of health needs, buying services to meet those needs, and a range of strategic efforts to improve health (Ovretveit, 1995). A strategic activity it may be, but commissioning is still a work in progress with many “commissioners” still being trained in what the concept involves.
Is commissioning simply “contracting”?
No. It’s a bewildering, multi-layered process with many objectives which involve large-scale system transformation. In apt business-speak for a business model, the “bottom line” is to achieve highest quality at minimal cost.
Commissioning in Cymru, Northern Ireland and Scotland:
Cymru/Wales
Northern Ireland
In Northern Ireland, a major review of Health and Social Care has been under way for the last two years. Due to political changes, the Commissioning side of this has been slow to develop. On 1 April 2009, the four former Health and Social Services Boards were replaced by a new single Health and Social Care Board. Membership of this Board has not yet been finalised. In addition, a number of Local Commissioning Groups have been set up, but it is not clear what their role in Commissioning, as opposed to that of the Board, will be. As such, Commissioning in Northern Ireland is best described as "work in progress". - Ken Fullerton
Scotland
Essentially we don't have commissioning in Scotland. There is no purchaser/provider split, but we find it easy to meet with government officials, having met with the Health Minister very recently. - Paul Knight |
Changing culture
By putting primary care at the heart of commissioning, the perceived domination of acute hospital Trusts has been challenged. Its themes include a move away from the hospital model towards community care, which is what service users say that they want and which is believed to be cheaper. It continues the erosion of centralised national policy in favour of local decision making. It encourages the development of partnerships between primary care trusts, local authorities and health professionals. There is also greater awareness of prevention.
Learning from the USA, and initiatives such as Permanente, a major US Health Maintenance Organisation, commissioning ideally involves an element of identifying and managing people with long term conditions before those conditions become crises leading to hospital referrals. The arrival of walk-in clinics and poly clinics, the expansion of community teams (GPs with Special Interests, nurse specialists, community matrons, case managers) are all initiatives born out of this aspect of commissioning. At the same time, financial inducements and penalties have been introduced to reduce prescriptions.
The Commissioning Cycle
Planning: Assessing needs and priorities; engaging the public; setting goals and health outcomes.
Execution: Designing and implementing care pathways around these needs; contracting from a plurality of providers.
Management: Policing the system - ensuring that it works; Identifying gaps; Managing demand and performance; Governance;
Monitoring: Evaluate service models and measure health outcomes.
Commissioning - the NHS’ “core weakness
While the NHS could not continue to swallow unchecked, the resources of the Treasury, the jury is still out on whether “commissioning” was the right process to achieve the first part of the highest quality for minimal cost equation. Primary Care Trusts - the commissioning teams, are not all fully trained, may not have the necessary expertise and they are not always engaging with the public or front line...in short, World Class Commissioning remains an aspiration.
What should the BGS be doing?
We should use every opportunity to champion the needs of old people, especially those who are frail, which is why the BGS Wales Strategy of using a frailty based model for commissioning seems particularly effective.
We will be devoting a UKMC meeting to this topic and then organising a study day on commissioning for old people. We hope to welcome senior people from the DH (the Director of Commissioning has already indicated a willingness to discuss things with us and we will use this opportunity to gently remind him of the central importance of elderly care in the NHS).
We need lead geriatricians on Commissioning in all the regions and the four countries (taking account of the different situations in the latter). These leads will need to become familiar with health economics. We will then publish and publicise best practice guidelines amongst those who would do the commissioning.
The Policy and UK Management Committees will be considering these in greater depth over the coming year and we would welcome the views of our members
Graham Mulley
President
Reference: Smith, J: A commissioning taxonomy for the NHS in England, Presentation at an ESRC Managing Scarcity Seminar. December 2005
BGS Newsletter, May 2009
Issue 21 ISSN 1748-6343 21 |