Where next for commissioning?

Commissioning should, in theory, be a key driver of high-quality public services in the 21^st century. However, in healthcare, commissioning is sometimes perceived as the ‘dog that doesn’t bark’. For example, the Five year forward view, which set out the NHS’s future strategic direction of travel from 2015 onwards, was largely silent on the role of commissioning.

After 25 years, it feels like the concept of commissioning in the NHS is at a crossroads. Questions over its effectiveness, structure and value for money abound. Sustainability and transformation partnerships (née plans, STPs), new care models and accountable care organisations and systems all challenge the concept of a separate commissioning structure and the long standing “purchaser/provider split”.

In healthcare, commissioning is sometimes perceived as the ‘dog that doesn’t bark’

Saffron Cordery    Interim Chief Executive

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At NHS Providers we have recently asked trust leaders and those involved in commissioning for their views on commissioning’s future and how it needs to change to deliver better health outcomes.  For me, it was interesting to explore the five key interlinked and overlapping themes that emerged from our conversations:

• The value of commissioning in getting closer to people… we need to put the patient first, and make the case for service improvement through better commissioning, co-production with patients and the public, and using commissioning to understand individual needs and incorporate them into the design and delivery of services
• …and understanding local place: alongside people, place also emerges as a critical theme both in terms of scale and geography. Although not clear from their name, STPs are essentially about place. Modelled on a set of defined geographical footprints, they exist to deliver better integrated health and care services to their population more efficiently and effectively, thereby better meeting patient needs. The scale on which STPs operate is now starting to change the shape of commissioners, providers and local government and how they inter-relate.
• The need to accept the emerging diversity of approach to commissioning structures: it appears that diversity is now opening up for commissioners and providers across the country. With STPs the potential for local partnerships to lead and shape bespoke arrangements is really emerging, and deliver services in a way that really meet local needs. In this context diverse experiences also come to the fore, and it will be vital that staff understand and gain experience of both commissioning and providing.
• The rapid blurring of the purchaser/provider split. It is starting to feel like this may have had its day, particularly in light of the new focus on place-based collaboration and the move to accountable care systems. There are rapid shifts developing in what were previously rigid boundaries between commissioners and providers. However dismantling this split is not without its risks and conflicts which need to be managed.
• Finally, the need to focus on commissioning as a strategic function. We need to elevate commissioning to focus on the strategic and ensure it delivers as much value as possible. This means shifting our perspective upwards and outwards, embracing longer-term, population-level issues. It is time to move away from the focus on the more ‘insular’ issues of tenders, procurement and contracts. Our current fixation seems to be micro not macro; tactical not strategic.

We do not need arguments about whether or not commissioners should be scrapped or whether the purchaser/provider split is dead. We need to fast forward to 2022, to work out what we want to have achieved for our populations by then, and identify the new approach to strategic commissioning that will help us do that.

Saffron Cordery    Director of Policy and Strategy

So, where next with commissioning?

I think we need a conversation at every level - local, regional, national - about how we create the strategic commissioning function: one that improves health outcomes at a whole population level, and moves away from low-value, high-cost, tactical contract management, procurement and tendering. Fundamentally we must ensure that we:

• focus on the magic formula of balancing economy of scale with patient involvement and clinician engagement
• recognise and respect the diversity of approaches that are now emerging. Variation can be seen as a negative but diversity must be embraced. What works in Wigan will not necessarily work in Winchester
• derive maximum value from our commissioning structure, mindful that we should maximise the resource devoted to patient-facing care
• learn from other sectors including, but not exclusively, local government, with its different, longer and, perhaps, more strategic experience of commissioning
• rule nothing out. Our next steps should be an enabling framework: a direction of travel rather than a set of prescriptive directions
• finally, set our sights on creating a strategic commissioning function that considers the needs of the population and then strategically plans to meet them within the available resources.

The next five years will be as challenging as the last. Commissioning is central. We do not need arguments about whether or not commissioners should be scrapped or whether the purchaser/provider split is dead. We need to fast forward to 2022, to work out what we want to have achieved for our populations by then, and identify the new approach to strategic commissioning that will help us do that.

Read the report online.

Read a blog in response to the report by Julie Wood, chief executive for NHS Clinical Commissioners.