Anthony Marsh, chief executive of West Midlands Ambulance Service NHS Foundation Trust, shares his view on where next for commissioning as part of Provider Voices - a new publication series from NHS Providers.
Our two biggest challenges are money and increased emergency activity. Ambulance trusts like ours, covering multiple clinical commissioning groups, see what commissioning looks like when it is done well (and when it is not done well).
We know what outstanding excellence for patients looks like. So our greatest opportunity, which I would encourage across the whole provider sector, is to think of the organisations that we know operate at the very best level, be it commissioning or other. If we, as a system, can reduce variation to get all organisations up to that level, we can provide even better care with the least spend on bureaucracy, and so the least corporate cost and overhead.
Sometimes in organisations, an individual or stakeholder sets a target, and if most people think that target is unachievable, there will be varying attempts to achieve it. But if we set achievable targets, as others are already achieving now, that removes any argument that ‘it might not be achievable’.
Our greatest opportunity is to think of the organisations that we know operate at the very best level, be it commissioning or other. If we, as a system, can reduce variation to get all organisations up to that level, we can provide even better care with the least spend on bureaucracy, and so the least corporate cost and overhead.Chief executive
And that is how we will be best able to match the very best organisations’ achievement. Because most people are competitive by nature, and want to do their best for staff and patients. There are provider organisations and CCGs operating at outstanding level, who inevitably will make further improvements. They want to be the best they can and seek ways to further improve and reduce operating costs at the same time.
Designing pathways for continuous improvement
Providers need to replicate very best practice, but also design pathways for continuous improvement. Ambulance services should all take personal responsibility for doing this. We will always have system levers and governance arrangements allowing commissioning to take place, and we also have the NHS Constitution and licence for provider organisations with respective regulators and legal framework within which commissioning must be conducted.
But across the system, this is about personal leadership and application of personal responsibility for all, regardless of role or where you work within the NHS to realise the ambition to provide world-class patient services and to recognise the huge financial pressure and address it in sustainable ways.
Sustainability and transformation partnerships
We have a great opportunity for the sustainability and transformation partnership (STP) process to be enormously helpful, but STPs will only achieve if they remove lots of other bureaucracy.
For example, over the last year, we have added a new raft of groups and infrastructure – we started off with over 200 CCGs, some of which are now working more closely together. Frankly, that is far too many, and mergers have only reduced by a few.
We have a great opportunity for the sustainability and transformation process to be enormously helpful, but STPs will only achieve if they remove lots of other bureaucracy.Chief executive
Then we added system resilience groups, urgent care networks, success regimes, vanguards, STPs, challenged health communities (27 providers whose emergency departments are working with the emergency care improvement programme), turnaround teams – and there will be others.
All of these have been introduced, and nothing has been taken out. That can’t be right. STPs can’t replace all of these, but we can’t keep on piling on new governance arrangements and removing nothing. That makes no sense.
Diversity of commissioning approaches
The development of ‘devo’ deals and new care models suggest that we will continue to have considerable diversity in how commissioning is delivered across the country. That need be no problem, if there is an absolutely clear direction of travel with the Five year forward view and what people are meant to be doing (in terms of the parameters and constraints on implementations).
If you stand back and look at it, we have clarity with the Five year forward view and national service frameworks, but all in a context of unhelpful duplication and fragmentation of other governance arrangements. The poor individuals trying to service it all end up with no time to do anything between meetings.
If you stand back and look at it, we have clarity with the Five-year forward view and national service frameworks, but all in a context of unhelpful duplication and fragmentation of other governance arrangements. The poor individuals trying to service it all end up with no time to do anything between meetings.Chief executive
We must always put the patient at the front of what we do, and work backwards. It does seem that with more duplication of the kind I have described that we have lost sight of the aim to improve care for patients and to support our workforce to be the very best they can.
In terms of focus on the patient, we have seen some experiments with outcomes-based commissioning. It will be a good thing to do if we can make it work, but there is a note of caution needed.
Providing value for investment in commissioning
After 25 years of various reinventions of commissioning, there seems to be a real issue about the scale of NHS commissioning units: both in terms of their size, and the cost of commissioning versus the value added by the commissioning process.
We can cite lots and lots of examples of extensive commissioning arrangements: Cambridgeshire, Hinchinbrooke, NHS 111, non-emergency patient transport service ambulance, and many of them collapse shortly after they go live. These are examples of commissioning that clearly didn’t work.
So we need to think about whether, given the substantial cost of commissioning, it really provides value for this investment. How does commissioning improve and add value? These examples – small and big – didn’t work.
Read the full Provider Voices: Where next for commissioning?