Radical changes to the delivery and commissioning of patient care needed, say new reports

The way patient care is commissioned, organised and delivered needs radical change if the NHS in England is going to respond to rising demand for care and a prolonged period of constrained budgets. That is the verdict of two reports published jointly today by independent health charities The Nuffield Trust and The King’s Fund.

The first report examines why nearly two decades since the introduction of a separation between local commissioners of care and health care providers in the NHS, commissioners have been unable to successfully challenge powerful hospitals. Recognising that commissioning is a difficult and challenging task and that it takes place at many levels within the NHS, the report argues that local commissioners have few effective levers for improving the quality of care and reducing the costs of providing it.

It proposes stronger engagement by clinicians in local commissioning, and suggests that in time primary care trusts (PCTs) may need to merge in order to secure greater management, analytic and clinical expertise; and have more purchasing clout to redress the historical imbalance with providers. However, it is likely that different commissioning arrangements will persist at different levels in the system from individuals (through personal budgets) to specialised commissioning (at national level).

The second report examines the potential for significant changes to the delivery of care through a new generation of clinically-led organisations that both provide and commission patient care. Lord Darzi’s NHS Next Stage Review outlined how these so-called integrated care organisations could improve the coordination of care for patients and led to a programme of 16 pilots*. The Nuffield Trust and The King’s Fund report focuses on integrated commissioner-provider organisations. Although the authors acknowledge the evidence base for the effectiveness of these organisations is as yet underdeveloped, they suggest this form of integration could offer potential for improving the efficiency and effectiveness of patient care across a range of providers.

Dr Judith Smith, Director of Policy at The Nuffield Trust, said: ‘The NHS is at a fork in the road – it cannot hope to respond to rising demand and the severity of the financial challenge ahead by continuing to organise and deliver patient care in the same ways. We now need radical new approaches ­– not just to boost commissioning but also to streamline the delivery of patient care across GP and community services and in hospitals to help people stay well and reduce avoidable hospital costs.

‘One option might be to encourage the development of integrated care organisations that are led by clinical staff, take responsibility for managing population health with a capitated budget for NHS funded care, and have much stronger incentives to provide the most cost-effective care. This would encourage clinicians to streamline care for patients and be much more proactive to support people to stay well. Some good examples are emerging in the NHS – it is early days but these models could offer the NHS its best hope of reversing the upward trend in avoidable ill health and hospitalisation.’

Anna Dixon, Acting Chief Executive of The King’s Fund, said: ‘Even the most optimistic of scenarios for public sector finances suggests that the NHS in England will have to achieve a step change in efficiency if it is to continue to meet quality standards. A combination of new models of care and much stronger commissioning that is outcome-focused will be critical if the NHS is to meet future demand.’

The key proposals put forward in: Where next for commissioning in the English NHS, by Judith Smith, Nicholas Mays, Natasha Curry and Jennifer Dixon, and Where Next for Integrated Care Organisations in the English NHS, by Richard Lewis, Rebecca Rosen, Nick Goodwin and Jennifer Dixon, include:

• A new role for PCTs: PCTs need to take responsibility for priority setting, funding and setting contracts with, for example, integrated care organisations, and holding them to account for quality, cost, patient experience and health. PCTs may need to evolve into fewer and larger funding bodies to meet these responsibilities.
• Handing commissioners more financial flexibility: changing some of the accounting and budgeting rules bearing on PCTs and practice-based commissioners to enable them to operate more like businesses by, for example, phasing financial commitments across more than one year. This should make it easier for commissioners to shift care out of hospitals into the community.
• Radical approaches to clinician-led commissioning: policymakers and NHS leaders should consider new models of health care provision and commissioning, led by clinicians in primary care and hospitals, which can deliver coordinated care for patients across different providers, particularly in the patient’s home. New forms of integrated care organisations that take the financial risk of a capitated budget to cover all care for a population have the potential to re-engage clinicians in managing services and securing more value for money.
• Public accountability: increasing the local accountability and public legitimacy of commissioners is vital. One option outlined in the reports would be to give them foundation status -enabling them to operate more independently of government control and with more active involvement of patients and the public. This could also go some way towards raising the profile and status of PCTs and practice-based commissioners in their local communities.