A major investigation into the practice of commissioning health care for people with long-term conditions has questioned the extent to which the NHS internal market in England operates as policy makers intended.
Researchers examined the ‘nitty-gritty’ of what commissioners do on a day-to-day basis, focusing on how they sought to develop and improve care for people with diabetes, dementia, and stroke.
The most striking finding was the sheer scale of the ‘labour of commissioning’ – the amount of meetings, discussions, planning, and analysis that goes into the review and commissioning of often small-scale service changes.
Indeed, the research raised uncomfortable questions as to whether this ‘labour’ was worth the outcomes secured for patients.
Commissioning should involve the drawing together of different professionals and interests around the common cause of services that can better meet patients’ needsDr Judith Smith, Director of Policy and lead investigator, Nuffield Trust
Commissioners were seen to act as the convenor of the local health system, bringing together different organisations and interests to plan and develop services.
What was less evident was the more transactional or hard-edged part of their role – using data to review and challenge existing service provision, halting the provision of services deemed to be ineffective, or contracting for new forms of care that would lead to significant change in how primary or secondary care are provided.
The findings and conclusions detailed in this research summary by the Nuffield Trust, arise from an in-depth two year study of commissioning practice in three high-performing primary care trust (PCT) areas (Calderdale, Somerset and the Wirral).
The full report Commissioning high-quality care for people with long-term conditions, was funded by the National Institute for Health Research Health Services and Delivery Research (NIHR HS&DR) Programme.
It warns new clinical commissioning groups (CCGs) that during a time of austerity they will need to make sure that they leave space for the more hard edged transactional work (specifying contracts, service review, decommissioning) in order to improve outcomes for populations.
The work of convening, engagement and planning will continue to be critical, but the balance will need to be somewhat redressed, especially given constrained management resource, and the requirement to achieve significant productivity gains from local health systems.
This research revealed the ‘labour’ of commissioning to be extensive and resource-hungry, especially when designing and specifying services.
Commenting on the report’s publication, lead investigator and Nuffield Trust Director of Policy, Dr Judith Smith said:
‘What was less evident was a robust approach to assessing the performance, quality and impact of local services, and willingness to provide necessary challenge to existing local providers.
‘With much less money available for NHS management the new generation of commissioners will need to pay close attention to the cost of their practice, display rigour in setting clear and measurable objectives for a programme of commissioning work, and ensuring that they can demonstrate that their effort is worth the candle.
‘They need to be mindful of when they need to stop consulting and engaging, and move to the procurement phase of their work, in effect when to ‘stop talking and cut a deal’.’
Several themes emerged from the study of commissioning across the sites. These included:
- The question of money: the role of money in commissioning practice was observed to be intermittent and at times peripheral. The organisational structure of PCT’s encouraged a separation of financial and contractual aspects of commissioning from developmental processes. A limited role was observed for NHS financial incentive schemes, but the majority of spending on the services studied was absorbed in block contracts;
- The scale and pace of change: changes brought about through the commissioning processes observed tended to be incremental rather than radical – they were cautious, carefully paced and non-disruptive. Success seemed to come where commissioners were tackling ‘bite-sized’ commissioning tasks as part of a wider local plan for service delivery;
- External drivers of commissioning: external drivers played a powerful role in shaping commissioning practice in each of the six service areas. National guidance provided top-down impetus to get things done, presented templates for services, and provided a national framework to facilitate local decision-making and identification of priorities. External support organisations were available for commissioners to call on to help their work.
The report concludes with a discussion of the activities most closely associated with effective commissioning, as observed by the study, and suggestions for practical indicators that could be developed to assess their overall effectiveness.
In terms of the former these include: introducing a greater emphasis on priority setting when decisions are made about how to spend local health budgets; maintaining a closer eye on the activity, financial performance and quality of services commissioned; focusing on the services that consume most of the budget and designing approaches that suit the particular service.
For example in the case of long-term conditions, developing contracts that share risk better across the range of providers responsible, and are run to longer time horizons.
Notes to editors
The National Institute of Health Research Health Services and Delivery Research (NIHR HS&DR) Programme was established to fund a broad range of research. It builds on the strengths and contributions of two NIHR research programmes: the Health Services Research (HSR) programme and the Service Delivery and Organisation (SDO) programme, which merged in January 2012.
The programme aims to produce rigorous and relevant evidence on the quality, access and organisation of health services, including costs and outcomes.
The programme will enhance the strategic focus on research that matters to the NHS. The HS&DR Programme is funded by the NIHR with specific contributions from the CSO in Scotland, NISCHR in Wales and the HSC R&D Division, Public Health Agency in Northern Ireland.
The National Institute for Health Research (NIHR) is funded by the Department of Health to improve the health and wealth of the nation through research. Since its establishment in April 2006, the NIHR has transformed research in the NHS.
It has increased the volume of applied health research for the benefit of patients and the public, driven faster translation of basic science discoveries into tangible benefits for patients and the economy, and developed and supported the people who conduct and contribute to applied health research.
The NIHR plays a key role in the Government’s strategy for economic growth, attracting investment by the life-sciences industries through its world-class infrastructure for health research. Together, the NIHR people, programmes, centres of excellence and systems represent the most integrated health research system in the world. For further information, visit the NIHR website.