Time for a fresh approach to commissioning

Many commentators within and without the NHS identify an under achievement of NHS commissioning. Commissioning, much like the practice of medicine, will be at its best when it conjoins art and science.

Good management has always combined both those key attributes so why generally has it been so lacking in the practice of commissioning? What has created an NHS focus on commissioning which is predominantly about setting contracts?  A focus on input procurement, and even within that narrow contractual approach there is a paucity of effective clinically-oriented contract review.

Much of the art lies in developing on-going multiple relationships with a particular reference to clinicians. Again, much lacking in commissioning practice which seems overly preoccupied with contractual relationships.

The proposed reform to the NHS is a response to the lack of engagement and involvement of the body clinical. It is after all clinicians and particularly doctors who ‘spend’ the money by their deployment of clinical resources.

There are purists who rigidly state that commissioning and provision must be separate. If that is the case, practising clinicians can never influence commissioning let alone lead it when the goal of successful health care management is to better align incentives. In particular to align clinical activity with budgetary responsibility, an aim that manifests across nations.

Commissioning is in its infancy compared to the literally hundreds of years’ history of provision – therefore an unequal power relation and task if we persist in a narrow and linear approach to it.

We need to re-define and extend the concept of commissioning without adding to, and in fact ideally lessening, the tasks it currently ascribes itself.

The NHS in general and its commissioners in particular usually adopt a very hierarchical and often reductionist managerial approach. In a complex adaptive system such as the NHS, linear approaches to management are of limited value and effect especially when it pertains to commissioning.

Effective commissioners need to exhibit clarity of purpose in a multiplicity of relationships, within a complex system.

The key roles for ‘new’ commissioners aggregate around four domains:

• Being the ‘people’s organisation’;

• Developing new relationships and partnerships within the wider public’s health eco system;

• Acting as the health care system leader across organisations, ensuring quality-safety, effectiveness and patient experience, and equally to promote innovation, productivity and integration across all NHS-funded providers;

• With a consequent fourth domain to have a new, and in reality a completely new, relationship with providers of care.

But NHS commissioners’ primary task is to be the local health care system leader across organisations with a clear focus on holism, accountability and outcomes.

Professor David Colin-Thomé is an independent health care consultant, and an Honorary Visiting Professor at Manchester Business School, Manchester University, and at the School of Health, University of Durham. David was also the National Clinical Director for Primary Care at the Department of Health from 2001 – 2007. 

This blog is based on Professor Colin-Thomé's paper, 'A new commissioning'. Please note that the views expressed in guest blogs on the Nuffield Trust website are the authors’ own.