Nick Moberly

Nick joined King’s in November 2015. Prior to this he served as chief executive at Royal Surrey County Hospital NHS Foundation Trust for nine years. Nick previously worked at King’s as director of strategic development from 2003 until 2006, when he played a key role in securing foundation trust status. He has held a variety of strategy and management roles in both the public and private sectors. He is a former first secretary at the Foreign and Commonwealth Office, and has worked as a strategy consultant for a range of blue chip organisations.

 

What is the big challenge facing commissioning today? It is easy to describe: in a nutshell, we have an exceptionally demanding set of expectations in the NHS in terms of the quality of services to be offered; the level of access people can expect to be commissioned; with inadequate funding available to pay for them.

Implicit in that challenge is the requirement for commissioners and providers to drive a transformation and change agenda, which is seriously tough. I have not known a time in recent memory where the tension between quality, access and money has been more marked. That is the challenge for commissioners - and so for providers.

We have an exceptionally demanding set of expectations in the NHS in terms of the quality of services to be offered; the level of access people can expect to be commissioned; with inadequate funding available to pay for them.

   

The corresponding opportunities are to seize the moment, and for commissioners who can find ways of working well and collaboratively with other agencies commissioning health and social care to make the most of the funding available and, working with providers, to rethink how services may be delivered.

These are genuine opportunities for progress, and in one sense, it is now a very permissive environment. There is willingness on the part of the Department of Health, NHS England and NHS Improvement to be very flexible and support pragmatic local agreements about how services should be managed.

Sustainability and transformation partnerships (STPs)

The underlying STP process recognises that individual organisations on their own can’t make the headway and progress that genuinely transforming care requires, so the only way to do improvement of quality and efficiency at scale and pace is for commissioners and providers in broad geographic networks to work on problems together in a collaborative way.

In geographies like south-east London, we have a strong, proud history of collaboration delivering results. Our STP puts a formal shape, structure and timeline to this, helping the process: we have found it helpful and beneficial.

   

In geographies like south-east London, we have a strong, proud history of collaboration delivering results. Our STP puts a formal shape, structure and timeline to this, helping the process: we have found it helpful and beneficial.

Looking ahead, we will collectively have to work out how to move from a high concept of what might be done to credible delivery plans for hard-edged change on the ground. That is achievable, but tough.

There are potentially significant complexities to think through as we go down this route: what are STPs formally, or perhaps what could they in time become? Are they a planning construct, an accountable delivery vehicle, or a formal part of intermediate-tier NHS governance? We as an NHS system have not thought this through yet. It is important to give this due consideration and clarity, as whatever we choose will have significant ramifications.

Making integrated care a reality

From a commissioning perspective, with everything under discussion, probably the most significant element of the STPs relates to making integrated care a reality on the ground.

What are STPs formally, or perhaps what could they in time become? Are they a planning construct, an accountable delivery vehicle, or a formal part of intermediate-tier NHS governance?

   

There is unlikely to be a single national definition or prescription of what integrated care is, and how it should be implemented. Different models will emerge in different geographies. However, in many cases the focus is likely to be on commissioning care based on detailed population analysis and risk stratification, using capitated year of care budgets linked to outcome measures, inviting providers to assume delivery risk. And that will profoundly change what both commissioners and providers are, and do.

To date, all we have is small-scale experiments in this direction. None have reached the point of being fully, securely implemented. But over time, in some geographies, we may see the establishment of substantial accountable care organisation (ACO)-type structures, whereby a provider grouping assumes the risk and responsibility for the delivery of care for a substantial sub-regional population.

Blurring of the purchaser-provider split

I certainly see blurring of the traditional roles of commissioner and provider ahead. Historically, commissioners have bought specified units of service for a given price. Increasingly, they won’t do that: they will be analysing their populations, stratifying according to risk, and setting outcomes-based measures of the health status and improvement they wish to achieve, and allocating providers block sums to deliver those outcomes.

And that means effectively seeking to transfer a great deal of risk to providers. To do so, the risk will have to be properly understood and priced, and providers will have to decide how best and most effectively to plan and deliver the required outcomes within the requisite resource envelope.

I certainly see blurring of the traditional roles of commissioner and provider ahead. Historically, commissioners have bought specified units of service for a given price. Increasingly, they won’t do that

   

The job of buying units of service could therefore go from commissioners to providers and, if so, commissioners would reduce their roles to focus on being more analytical and less hands-on. We will have to see. People need to consider that if they develop strong, functioning ACOs, the commissioning role will not be eliminated, but it could be very seriously reduced.

How far are we away from that? As in the rest of NHS, we are at the very early stages. There’s considerable agreement on the direction of travel: join up the system and create integrated services.

But there is a long road ahead to make it a reality. Yet there are interesting opportunities to move fast in the next couple of years. Lambeth and Southwark have formed local care networks, which could be the basis of an integrated care organisation, as has Bromley.

We can move quickly, but nowhere across the NHS have we yet seen integrated care implemented systematically at scale and to a point of demonstrating delivery. Vanguards show interesting early experiments of what might be achieved.

A more consolidated model of commissioning

From a commissioner perspective, one important issue linked to all of these emerging changes is that of scale. Increasingly, as STPs take hold and sub-regional planning takes place, we have to ask whether CCGs are operating across too small a geography. And in principle, a more consolidated model might make sense as part of a move to novel ways of commissioning, based on integrated, population-based analysis and outcomes-based capitated budgets.

From a commissioner perspective, one important issue linked to all of these emerging changes is that of scale. Increasingly, as STPs take hold and sub-regional planning takes place, we have to ask whether CCGs are operating across too small a geography.

   

But for that, CCGs would need new significant skills, which are not found anywhere in the NHS on a systematic basis. Not to mention money and capacity.

Moreover, CCGs have done much to address close collaborative relationships within geographies. CCGs have been a significant improvement on the old primary care trust world, with much stronger clinical focus, and in general have made relationships stronger and more productive.

Another challenge: people need to realise that health and social care are a contiguous and fairly seamless set of activities. The challenge for the health side is how to work closely with social care while that is resident in the local authority sector. Both increasingly need to be joined-up – which can work well or badly locally.

In terms of using individual budgets to guarantee a more personalised service, it is unclear how that would work. In principle, you could see a significant disconnect between individualised budgets and an ACO-type approach focused on capitated, risk-stratified budgets for a population.

People need to realise that health and social care are a contiguous and fairly seamless set of activities. The challenge for the health side is how to work closely with social care while that is resident in the local authority sector. Both increasingly need to be joined-up – which can work well or badly locally.

   

Presumably an ACO would wish to make quite a few of the calls on what care process best delivers a specified outcome.

The future of the purchaser-provider split

There will continue to be a role for a party in any health system to understand population health needs, determine outcomes and allocate funds. Equally, there needs to be a counter-party assuming responsibility for delivering that. That is the difference between resource allocation and delivery. But in terms of how we see the purchaser-provider split currently, the nature of that relationship will change significantly. Even if the future is not clear, the system of payment for units of work undertaken on the payment by results tariff (PbR) seems unlikely to persist in its current form.

But that is looking like a reasonable distance into the future. The PbR model was powerful in a time when the policy focus was to drive down waiting lists when budgets were rising strongly. Getting the finance system right is much harder when the policy focus is about doing the best care within a finite resource base.