Author: Dr Judith Smith

Date: 29/04/2010

Organisation: HSJ

Extract:

Only radical new approaches will take commissioning forward after the election.

Commissioning has received an unequivocal guilty verdict from the Commons health select committee. Guilty of being powerless in the face of hospital providers, failing to shift care into community settings, and not securing sufficiently high quality specialised services.

The committee report points the finger squarely at the 152 primary care trusts in England, accusing them of being the weak link in the NHS. The implication is that if only PCTs were doing their job properly, and being “strong” or “world class”, many of the problems in the NHS would be solved. This report will have left PCT commissioners feeling undermined and concerned about their future beyond the general election.

Practice based commissioners received less attention in the report, but were similarly written off as having largely failed to engage GPs in leading radical service change.

But the report missed some fundamental issues. First, it paid scant attention to the fact that political will (or lack of it) gets in the way of commissioners trying to bring about change. It is too easy to blame commissioning for not doing what is profoundly unpopular and difficult, namely downsizing or closing hospitals.

Second, providers have the dice loaded in their favour, with foundation trust status bringing financial freedoms and funding that rewards hospitals for treating ever more patients.

PCTs and practice based commissioners struggle to influence referrals, in particular those between consultants, or the level of admissions through accident and emergency. This means PCTs are frequently unable to extract resource from providers and develop community based alternatives.

So what needs to be done if PCTs and practice based commissioners are to have a fighting chance of making the efficiency gains and service transformation exhorted in the party manifestos?

It needs a fundamental realignment of healthcare delivery and resource management that places GPs and other clinicians firmly at its heart. This will require radical new approaches.

First, there is a need to incentivise GPs and hospital clinicians beyond practice based commissioning into taking on real risk-adjusted budgets with the promise to keep any savings to reinvest in patient care.

Clinical partnerships

As a recent Nuffield Trust and NHS Alliance report outlined, this would require large groups of clinicians to form partnerships to assume responsibility for the health outcomes of their local population, and accountability for financial performance and patient experience.

Second, if such partnerships undertake much more active and extensive commissioning for local communities, PCTs are likely to become fewer and larger. Their role would increasingly be the designer and manager of the local (or regional) commissioning system, allocating budgets to local clinical partnerships, specialised commissioning networks, joint commissioners and people with personal health budgets - and holding such groups to account for outcomes.

Third, as another recent report by the Nuffield Trust and King’s Fund recommended, PCTs and practice based commissioners will need more financial flexibility, such as being able to retain surpluses and invest across different years. More unbundling of the payment by results tariff will also be needed if it is to extend to community and other services, and be used to lever new models of care that cross traditional boundaries.

Finally, commissioners will need to have much greater public visibility. Ways of achieving this include extending foundation status to PCTs or local clinical partnerships, or offering people a direct choice of commissioner.

NHS commissioning is at a fork in the road. It could limp along making minor changes and continuing to put faith in world class commissioning. But this would lose time, something that is now in short supply.

The alternative is a radical model of clinician led commissioning held to account by fewer and larger PCTs. This will require courageous leadership, and a willingness to think again about incentives.

This leadership will need to come from politicians, managers and senior clinicians. It does at least offer the possibility of at last being proven to be something other than weak.

Read this article on the HSJ website

back to top ↑