It’s the end of the world as we know it… or at least as most people now working in the NHS know it. The purchaser/provider split came into being with the NHS and Community Care Act 1990 and the establishment of NHS trusts.
Since then, although there have been many reorganisations, only three changes driven at a national level have had any direct impact on NHS provider organisations – the creation of primary care trusts (PCTs) in 2000, which brought together commissioning of all services for a population and the delivery of community services. Then came the establishment of foundation trusts from 2004, and the separation of community services from PCTs by 2011/12.
Those latter changes were expressly designed to enhance the separation between commissioning and provider functions.
Today, we’re looking at a different change, which will have profound implications for both providers and commissioners. The creation of integrated care systems (ICSs), and perhaps going further to establish accountable care organisations (ACOs), is perceived by some as a return to an earlier world of district health authorities and directly managed units. A world where most contracts were contracts of employment, budgets were set on the basis of the previous year’s spend, and there were next-to-no performance measures, whether relating to outcomes, access or quality.
Well, we’re definitely not going that far. Notwithstanding the debates around terminology, accountability is rightly an important concept in our world now, and the success – or otherwise – of ICSs will be measured by how well they deliver improvements in population health and the experience of health care within the resources available to them.
But sweeping statements have been made about the ‘end of the purchaser/provider split’, and the ‘death of commissioning’. We want to explore the reality behind those statements.
Lessons from the past
The ‘World Class Commissioning’ framework was used to assess PCTs between 2008 and 2013. Although the title was somewhat grandiose, the framework itself provided a very useful checklist of commissioning roles and activities that need to exist in a system. These included:
- working collaboratively with community partners to commission services that optimise health gains and reductions in health inequalities
- proactively seeking and building continuous and meaningful engagement with the public and patients, to shape services and improve health
- leading continuous and meaningful engagement with clinicians to inform strategy, and drive quality, service design and resource utilisation
- managing knowledge and undertaking robust and regular needs assessments that establish a full understanding of current and future local health needs and requirements
- prioritising investment according to local needs, service requirements and the values of the NHS
- promoting and specifying continuous improvements in quality and outcomes through clinical and provider innovation and configuration
- effectively managing systems and working in partnership with providers to ensure contract compliance and continuous improvements in quality and outcomes.
There is little in this list that we would not want to see happening in the NHS of integrated care systems, although we might describe some of them differently these days. In many ways, as long as we have a shared language, the terminology we use is unimportant – what matters is that the tasks required to ensure the delivery of high-quality services that improve health care and health for a population are delivered somewhere in the system.
Over the next few months, we will consider how the functions currently undertaken by commissioning organisations might evolve as ICSs and ACOs develop.
We begin today by considering the future of commissioning in the context of integrated care.
Buckingham H (2018) "Commissioning: the times are a changing", Nuffield Trust comment. https://www.nuffieldtrust.org.uk/news-item/commissioning-the-times-are-a-changing