Commission impossible?

James Gubb, 28 July 2008

‘It’s simply not possible to transform health care to meet the needs of the 21st century without strong initiatives that focus on the demand side; no matter how good the regulator is’, opened Mark Britnell at the latest in Civitas’ series of debates on NHS reform.
The NHS’s history, he put it, has been one of provision; never before has the NHS really done commissioning. Previous attempts have merely redefined supply and re-written contracts, with minimal impact on health.

Commissioning is different. It seeks to ‘add life to years and years to life’; its vision is focused on outcomes, it starts with an absolute and profound assessment of need and decisions on services should be driven by meeting this.
There’s a framework in place to help PCTs to do so in the next three to four years, but for the first time, contended Mark Britnell, they are free to ‘put their money where their ambition is’ in investing over three to five year periods.
Mike Farrar believed there could be further benefits too. For the first time, he said, ‘the right sort of questions [are being asked] about how accountable you are for expenditure’.
In his view – and many others taking part in the discussion – world class commissioning absolutely necessitates connecting back to the people whose money is being spent, to both cement its legitimacy and engage people in taking responsibility for their own health.
Perverse incentives?
But, while being positive about the potential of world class commissioning, the panellists also highlighted numerous risks and obstacles.
Mike Farrar drew attention to a conflict between means and ends. Is world class commissioning a means to better health and health care or an end in itself to achieve increased legitimacy in the delivery of health care?
Dr Mike Dixon added to this, cautioning that previous performance frameworks for commissioners have not achieved much, if anything. He sees a real danger of conflict between practice-based commissioners and PCTs living in a ‘parallel universe’. To PCTs, SHAs and the DH, he contended, commissioning is talk of ‘metrics, diagrams and arrows’, which is unlikely to take in the reality of day-to-day consultations ‘in the marshy bog-land of real life’. Approaches need to be coordinated.
However, for Dr Tim Richardson the problems go deeper than this; world class commissioning will remain incredibly difficult while ‘you have so many different organisations providing so many different elements of the same patient’s care [through so many different contracts, producing] so much potential for gaming and losing the patient’.
Instead, he sees a solution in integrated care pilots, which would allow primary care to provide patient services in collaboration with secondary, community and tertiary care in a single contract. With full transfer of risk, there he sees real potential ‘to move away from the current silo approach where patients fall down the drain’.

A change of culture
In his summation, Professor David Fish put the case that ‘the yard stick for world class commissioning won’t necessarily be an excel spreadsheet, but the leadership qualities of the commissioners who knock on the door’.
This will, as Mark Britnell warned, require an investment in a completely new skills subset; ‘no-one is born a natural commissioner’.
But it will also require flexibility, leverage, peer pressure and humanity; things that don’t easily lend themselves to measurement. As Dr Mike Dixon surmised ‘the choices [key to commissioning] depend on very human things like relationships, trust, integrity and things like how you can motivate people or perhaps even persuade them’.
This requires a cohesiveness of the kind the NHS has struggled to find in recent years.
For the full discussion see here.