The Government’s reforms to health and social care remain as controversial (and arguably uncertain) as ever. Yet despite being the subject of heated debate, the rationale for the reforms remains poorly understood and articulated by its champion. A year on from the publication of Equity and excellence, the MHP Health Mandate team will revisit the key themes which underpin the reforms, examining their origins and their potential to change health service delivery. In this article Martha Burgess and Ben Nunn discuss commissioning.
Changes to the NHS’ commissioning architecture have been at the centre of both the rationale behind the Government’s reforms and the ensuing critique and debate. Andrew Lansley’s initial proposal to do away with primary care trusts and strategic health authorities, passing much of the health budget to groups of GPs, left the health community divided as to whether bureaucracy would be reduced, and whether GPs would be capable to make financially astute and patient-centred commissioning decisions. This is certainly not the first time that the health world has been left asking questions and debating relative levels of bureaucracy, scope for inequalities and clinical commissioning expertise and, based on recent performance, this is a debate which will rumble on for time to come.
Looking back at the history of NHS reform, Rachel Rowson considered the history of commissioning, starting from the failed GP fund holding model introduced under the Thatcher Government, where the budget was placed directly in the hands of GPs, enabling family doctors to hold funds to buy healthcare from local providers. The non-compulsory system was criticised as a two tier NHS emerged, when patients in areas where fund holding was in operation were often able to access services more quickly than those where it was not.
When Labour came in to power in 1997 they were quick to call an end to GP fund holding, returning to a system of local primary care organisations planning services on behalf of their population. Commissioning under the Labour Government, though, was hardly plain sailing. Consecutive attempts to deal with the challenges of NHS commissioning, and to create the ‘right’ size of health economy, meant that the number of commissioning organisations fluctuated and there was often little time left for the new organisations to bed-in before further reorganisation were announced.
The Labour Government saw the merit of clinically-led commissioning, with the introduction of practice-based commissioning in 2005. This new style of healthcare commissioning allowed groups of GPs and other clinicians based in the community to help develop and commission better services for their local health economy. PCTs remained the statutory fund holders, but those on the front-line were supported and resourced to be involved in the commissioning process. It was expected that this type of commissioning would lead to high quality services which were designed to deliver what local people wanted and needed, however, as with other reforms practice based commissioning was patchy across the country and not given the time to become an embedded commissioning process.
It is against this backdrop of persistent change to NHS systems and structures that led the Coalition to pledge a move away from top-down reorganisation of the NHS.
What these various commissioning organisations have in common is that they have absorbed much of the blame (rightly or wrongly) for failures and inequalities in the NHS as a whole. Numerous inquiries by the Health Select Committee (both from this Parliament and previous) have highlighted problems with commissioning, including:
- an inability to evaluate data and identify cost-effective, evidence based interventions
- some organisations lacking the required knowledge and experience to commission services effectively
- weaknesses in strategic planning capabilities
- variations in the quality of commissioners and the services they commission
So, is it possible for the current set of reforms to overcome these longstanding challenges?
For Andrew Lansley’s reforms to work in practice, the Government will have to get the commissioning structures right. The delay in the development of new structures does allow for further clarification in this area. However, there is still much to be done in terms of finessing the detail and understanding how the commissioning structures will work in practice.
In his first conference speech as Health Secretary, Andrew Lansley launched an attack on the bureaucracy of the NHS. He said that the Government would “sweep away all that top-down bureaucracy that prevents doctors and nurses making the best decisions for their patients.” He added: “Out go two whole tiers of state-led management and oversight, reducing management costs by £850m by 2013/14.”
His attack on NHS bureaucracy was hardly new. The argument has been behind most reforms of the commissioning infrastructure and has been one that Lansley and his ministerial team have frequently returned to in defending their reforms, based perhaps on the idea that the view of the public and the media is that money spent on management would be better spent on frontline NHS care.
Lansley’s plans set out the development of an NHS Commissioning Board. Holding overall responsibility for £80 billion of the NHS budget, the Board will be responsible for commissioning most NHS services, largely from GP-led clinical commissioning groups. Following the pause in the passage of the Health Bill, the Board will now also include local commissioning arms, in part taking the place of primary care trust clusters. It will also be supported by “commissioning sectors” which will reflect four strategic health authority clusters.
Unsurprisingly it has been argued, mostly by those opposed to the reforms entirely, that these changes will add bureaucracy to the commissioning system. At a recent Health Select Committee session, Clare Gerada, Chair of the Royal College of GPs, argued that the number of statutory NHS bodies would rise from 163 to 521. Only last week, the Shadow Secretary of State for Health quoted the NHS Chief Executive, Sir David Nicholson who described the NHS Commissioning Board as the “greatest quango in the sky”. Regardless of the numbers, Andrew Lansley’s claim that he would wipe out two tiers of state-led management now seem to have been a little premature.
The decision to retain SHA and PCT clusters in some sense is arguably a “mechanism for retaining a grip in a ‘liberated’ NHS”. They have been seen by many as a concession to Sir David Nicholson, who will head up the NHS Commissioning Board, to ensure him that it will be possible to retain some central control over the work of local clinical commissioning groups.
Regardless of the reason for their stay of execution, there will be an important job to do for the NHS Commissioning Board, which will host the SHA and PCT clusters, as well as clinical networks and senates, to ensure that their operation does not add to the perception of bureaucracy in the NHS.
Clinical and patient involvement in NHS commissioning has been a key strand of Andrew Lansley’s reform agenda, and indeed previous attempts at reform.
The Health and Social Care Bill makes clear that commissioners will need to ensure patients and their communities are involved throughout the commissioning process. This is not unlike the duty that currently exists for PCTs and SHAs to make arrangements to ensure patients and the public are consulted in decision making. The shift towards clinically-led commissioning is designed to drive an NHS which is led, not by NHS managers, but by clinical experts. Again, very much like practice-based commissioning.
While the shift to clinical commissioning has largely been welcomed, many groups have demonstrated concerns about the breadth of knowledge and experience of GPs. Following the Government’s response to the NHS listening exercise, GP commissioning consortia have been rebranded as clinical commissioning groups and will now take advice from a wider range of clinicians when planning and commissioning local NHS services. Hospital doctors and nurses will now join the boards of clinical commissioning groups, which will also need to seek advice from allied health professionals, public health specialists and others. This in turn may create its own problems, in implementation at the very least. The need for a purchaser (the commissioners)-provider split has long been accepted, and successive changes have been made to ensure that those buying care will not financially benefit from its provision.
The Department of Health has always been keen to address the issue of conflict. As such, the responsibility for commissioning primary care services will be in the hands of the NHS Commissioning Board rather than GPs. But how will this work with hospital doctors and nurses? The Department has confirmed that these healthcare professionals will not be able to join commissioning groups for their local areas because of the clear conflict of interest. This does beg the question about how interested doctors and nurses will be in commissioning if they have no say on their local services, and how their involvement will be ensured.
As research by the King’s Fund found, the success of practice-based commissioning often relied on a number of enthusiastic health professionals who came together voluntarily rather than having their relationships or structures imposed by their local PCT. As Natasha Curry rightly points out “the new arrangements allow these natural groupings to emerge but one potential problem is that some may not be large enough to manage risk”.
Increased involvement of other professionals, such as nurses and consultants, has allayed some concerns about the spread of expertise involved in commissioning. Another challenge that has faced the reform, has been the future of commissioning support. In this, too, there has been compromise. Ahead of the pause many charities were concerned that GP commissioners would not have access to appropriate support and expertise. This was particularly the case among cancer campaigners, where the involvement of cancer networks has meant that the support available to local commissioners has been more developed.
The Future Forum recommended, and Government accepted, that clinical networks and clinical senates should form a key part of the new system architecture. Clinical networks and clinical senates are intended to reassure those who feared that GPs would not have the necessary expertise to commission specialist services, or the desire to seek help in doing so.
While networks and senates now have official backing, not only from the NHS Future Forum but also from the Secretary of State himself, there is much detail yet to be established as to what they will look like in the longer term. It will not simply be a case of retaining the networks that currently exist.
In the case of cancer networks, their performance (and indeed their role) has been something of a mixed bag. While some cancer networks have achieved significant improvements in outcomes for patients, others have been less well established. A census of PCTs carried out by the National Audit Office found that only 71% of primary care trusts said that they worked very effectively with their cancer network in the delivery of cancer services. This fact is no doubt behind the review of clinical networks now being carried out by NHS East Midlands medical director Kathy McLean on behalf of Sir Bruce Keogh. As Mike Birtwistle recently wrote, work now needs to be undertaken to develop the network model, ensuring they have adequate commissioning expertise and that there is clarity about which parts of the pathway their support will be focused on.
The same will be the case for clinical senates. While the commitment to their existence will encourage some that there will be more central control, their role and mode of operation still needs to be unpacked. Widely expected to be made up of the ‘great and the good’, they will need to establish themselves as truly independent and clinically-led bodies, particularly if, as some expect, they will take on the role of making the case for clinical change and reconfiguration in the NHS. If they are to succeed in this where others have failed they will need true autonomy and experience.
Despite these debates in Westminster, the NHS is largely already getting on with implementing the reforms. PCTs and SHAs have formed clusters, and pathfinder clinical commissioning groups have been setting up in shadow form for some months. Before the Health and Social Care Bill has completed its long journey through Parliament the NHS Commissioning Board will be in operation in shadow form at least. This offers both opportunities and challenges.
The existence of pathfinder clinical commissioning groups will allow for the proposal to be tested, and perhaps for some of the debates outlined above to be resolved. As we wrote back in April, it is already possible to undertake analysis of the priorities being adopted by the next generation of commissioners. Across the country clinical commissioning groups are planning services in their local area, and in many cases have taken over responsibility for budgets. How the best of the early adopters manage the process, and how they seek advice and help, may well inform future structures and guidance.
And yet the system in which they will ultimately operate is not yet in place. In many ways the earlier establishment of these groups may mean that further changes, and so further disruption, are necessary down the line. The fact that the NHS Future Forum recommended that, unless there is a very good reason, clinical commissioning groups should be co-terminous with local authorities, will mean that some of the existing groups will need to adapt before they have been formally created. This is because many of the pathfinder GP commissioning consortia which have sprung up to date have crossed local authority boundaries and will need to divide and merge with other groups to be co-terminous with upper-tier local authority areas.
Clarifying the structures and processes is going to be essential. With the key structures and bodies now confirmed, the NHS Commissioning Board, and its chief executive Sir David Nicholson, will have to start working on the specific details. Sir David will need to show how the NHS Commissioning Board can set out the improvements in outcomes at the centre of the rationale behind the reforms. Central to this will be mechanisms and levers such as quality standards and the commissioning outcomes framework.
If this reform of the NHS is to succeed in developing a successful commissioning architecture where others have failed, then those leading it will need to learn from both failures and successes of the past. Much maligned commissioning, when properly prioritised and resourced, has the ability to improve outcomes for patients while also saving money for the NHS. PCTs have seen improvements since their inception, and our analysis has shown that effective commissioning involving prioritisation of performance indicators does lead to improved outcomes in certain areas.
Learning from both the failures and successes of the past will therefore be key.