David Evans, chief executive of Northumbria Healthcare NHS Foundation Trust, shares his view on where next for commissioning as part of Provider Voices - a new publication series from NHS Providers.
My honest opinion is that the purchaser-provider split has outlived its usefulness. The NHS environment has changed hugely from the time when commissioning seemed like a good idea. Back then, there was plenty of money in the system, and options for getting better deals for your money by managing the market.
Now money is tight, the question must be whether money spent on commissioning wouldn’t be better used delivering services. Look at the situation nationally: some providers are in dire financial straits and their commissioners sit on surpluses. In other places, the reverse applies.
We have seen private providers hit this wall too, as well as some high-profile commissioning decisions (as in Cambridgeshire) that fall foul of the reality of providing services.
The value of accountable care organisations
Moving to something like accountable care organisations (ACOs) must be worth a try, as a way of making best use of the money in the system.
If many people in the NHS look up what an ACO is in the USA context, they will probably find it scary. Some American ACOs are, frankly, aggressive money-making institutions. We have aligned ourselves with Ribera Salud Grupo in Valencia. We like their concept of a truly integrated service out of hospital, run by a joined-up delivery system: that is where we want to be.
Since September 2011, we have managed the adult social care contract for Northumberland County Council so we are a step or two ahead of the integration game, and of letting the financial systems support it.
Now money is tight, the question must be whether money spent on commissioning wouldn’t be better used delivering services. Look at the situation nationally: some providers are in dire financial straits and their commissioners sit on surpluses. In other places, the reverse applies.
chief executive
So we have adopted and adapted a model from Europe, which we think aligns systems and ways of working. Our health economy has a long history of joint working and a stable, sensible and grown-up set of financials which can only support this system, especially when the overall NHS financial package is as tight as it can be.
Sustainability and transformation partnerships
Our sustainability and transformation partnership (STP) footprint is so large that we are in with the rest of the north-east of England. We are confident that our system is good and functioning, but to get all the rest to follow our model would be a big ask. As with all STP footprints, the changes are going to be challenging.
STPs seem like a broad-brush effort to get people to sit up and think and be in the same room working together – which some organisations have never done, so that will be good. The idea that they can deliver quickly may need revisiting – our clinical change in Northumbria took years and years. Many service changes need consultation and political sign-up, which take time.
There are some quick fixes and things that should have been fixed years ago. Taking a mid- to long-term view, it is good for organisations to sit down together and get their homework marked, but there is a lot of work to do.
STPs seem like a broad-brush effort to get people to sit up and think and be in the same room working together – which some organisations have never done, so that will be good. The idea that they can deliver quickly may need revisiting – our clinical change in Northumbria took years and years. Many service changes need consultation and political sign-up, which take time.
Chief executive
The scope and scale of the changes proposed is enormous: Sir Bruce Keogh, shortly after his appointment, suggested the NHS has never had an honest conversation with the British public about what it can deliver, and I think that point still stands. Treating long-term conditions better is the real challenge – the NHS is facing a bow-wave of demand and demographics.
Service transformation takes longer than you think
Our ACO concept was part of the integrated primary and acute care systems (PACS) vanguard, but the pace was meant to be slower. We planned to implement in year five; now we are being asked to implement it in year three. All involved here were comfortable with the longer timescale.
In my experience, major service change takes between 5 and 15 years. Our provider A&E reconfiguration took 15 years, 6 years' thinking and 9 years' planning to achieve what we did – then there was the political stuff, the planning, legals, buying land, building, training. You don’t just flip a switch.
Looking at what is happening to clinical commissioning groups, they are in a very hard position. Some are doing great, declaring big surpluses, but then you look at their providers in deficit, and you think ‘with one pot of money – is that success?’
There has been a big shift of risk onto providers. You see glimmers of hope with personal health and education budgets, illuminating how the shape of healthcare delivery will differ.
The devolution agenda has become a bit uncertain. The proposed north-east devo deal has been called off, so we are watching ‘devo-Manc’ with interest.
To me, the real deal is about moving to the Riberia Salud-type ACO model. A few years ago, everyone was talking about the Geisinger and Kaiser Permanente models, Northumbria and Torbay colleagues first met on [The King’s Fund chief executive] Chris Ham’s ACO group US tour. Those US ACOs have a joined-up, integrated system working in a very different marketplace, but they are very profit-driven (and they do deliver some fantastic services). We have dipped into a range of ACO-type systems around the world: the Riberia Salud model looks like it could work in the NHS.
The devolution agenda has become a bit uncertain. The proposed north-east devo deal has been called off, so we are watching ‘devo-Manc’ with interest.
Chief executive
Thinking about how in future, nationally commissioned, specialised services will interact with local commissioning, it wouldn’t hugely affect our model. We have long had a ‘hub and spoke’ arrangement with Newcastle for specialised services, and that has worked for both parties.
Co-commissioning for primary care
Then there is the question of how co-commissioning for primary care fits with an ACO model. We are getting legal advice, but it seems that CCGs will keep a small strategic commissioning role based in the local authority, and the rest becomes part of the ACO. From being a PACS vanguard, we have seen that joint work around integrating primary and secondary care can deliver real improvements. Will it enable us to remove money, though? We will see.
If it is really about making the best use of what resources we have, I think this offers an opportunity. It is also an opportunity to let specialist staff, traditionally based in hospitals, work in communities, especially clinical pharmacists – who are fantastic on medication reviews in care homes, and on chronic disease management in primary care. So, there are obviously good clinical moves to be made.
The traditional business model of primary care makes it very hard for practices to employ expertise without being part of something bigger. Given our serious shortfall of GPs, different models of staffing primary care must be part of the future. The acute sector’s specialist practitioners and nurses could offer as-yet unrealised potential for primary care.
If co-commissioning for primary care is really about making the best use of what resources we have, I think this offers an opportunity. It is also an opportunity to let specialist staff, traditionally based in hospitals, work in communities, especially clinical pharmacists – who are fantastic on medication reviews in care homes, and on chronic disease management in primary care.
Chief executive
Training a GP takes a decade. It takes one to three years to train a pharmacist up from a master of pharmacy to independent prescribing. We have had pharmacists integrated as part of frontline teams for a long time, and on medicines management in care homes and GP practices. This is vital to building the alternative workforce, and secondary care has been expanding pharmacists’ roles for a long time. Now there is an opportunity for primary care to do this in making a more joined-up system: the economics become easier.
Personal budgets
I haven’t seen the personalised budgets concept explored to its full potential. We have some knowledge from other sectors: education and long-term handicap: and it has worked well where it has worked well, but I have not seen proper evaluation. It is a concept the NHS is yet to fully explore, but it is interesting.
Another interesting concept is outcomes-based commissioning. Cambridgeshire has obviously had a big problem with trying it, but in theory, it should be workable around data, agreeable risk sharing and standards, if we can make it work and if it is better for patients, why not?
The need for reform
I believe we have to change. The current system cannot deliver what is needed to support our population in the future even if funding was unlimited. The divisions between primary, secondary and tertiary care used to seem straightforward but I think will not deliver for the future. A system for managing, commissioning and funding pathways must help.
Our reactive system of a National Sickness Service, rather than a truly anticipatory health service, has to change. It is obviously good that more people are living for longer, but with complex conditions, community-based support and avoidance of acute admission must be the goal. Hospitals need to change from being refuges for acute illness to centres of expertise supporting community-based services to safely manage individuals in their home to avoid the need for acute episodic care.
Read the full Provider Voices: Where next for commissioning?
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