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What now for commissioning?

By Professor David Colin-Thomé, OBE, chair of PCC and formerly a GP for 36 years, the National Clinical Director of Primary, Dept of Health England 2001- 10 and visiting Professor Manchester and Durham Universities.

David Colin-Thomé

NHS policies since 2014 have increasingly been provider orientated leaving commissioners in at the least, a state of flux. Commissioners in general have had little impact on primary care largely as contracts for the independent contractors are negotiated nationally, but local opportunities have arisen in the past. During the NHS Reforms of 1991 many commissioners supported the development of practice based budgets; Personal Medical Services (PMS) a national policy introduced in 2004 and updated 2015, initially offered an opportunity to locally rectify or at least ameliorate the historic lower funding of GP practices serving social deprived populations. In the Primary Care Home programme commissioners who supported the programme demonstrated their most significant support to primary care.

Maybe the clue could be in the name, not buying quantity and forcing quality but commissioning high value care for patients with value defined as the health outcomes achieved for money spent. Commissioning should entail enabling providers who possess almost exclusively the clinical knowledge, to set their own quality and performance indicators against which they will hold them to account. It would be naïve to think all providers will without hesitation set high and stretching indicators, in which case commissioners will need to rigorously apply the available local and national quality indicators implemented piecemeal around the country. Enabling and then holding to account is paramount and patient involvement and feedback mandatory.

What of the commissioning of primary care? General medical practice and PCNs are provider organisations which by dint of their population responsibilities can undertake some of the current roles of commissioners and ideally beyond. To go beyond healthcare and to be ‘of the people’ all NHS providers must be working to embrace population health. Hospitals argue, wrongly, that they have little impact on some of the broader healthcare determinants, such as obesity, exercise or smoking, and that it is somebody else’s job. It is certainly a challenge, but hospital clinicians are highly influential, especially from a patient perspective. . Arguably the main failure of NHS commissioning in its present mode of working is its inability to improve the value of hospital services and ensure whole healthcare system working.

Partnerships between commissioners and all providers can manifestly optimise where and by whom care is delivered and where achieved, the new way of working embedded and spread. Uncommon practice in the NHS where piecemeal is often the order of the day, but hopefully much more achievable with the development of larger and more strategic commissioners. All providers should take a population responsibility and a growing number are. What an opportunity for providers and commissioners working in an openly accountable partnership. Structure and formal working being insufficient in itself to elicit change, a leadership imperative is the identifying and sustaining of allies and alliances from all parts of the health and care system of those who wish to work in new ways.

NHS Policy is promulgating organisations to work in systems thereby adding value to their solo working. There is a novel challenge for commissioners as the NHS comes to terms with a policy shift from its classic nationalisation and hospital centric past. Not only how can PCNs be commissioned but how to commission for the individual patient who currently has little influence and choice? Complex issues can only optimally be addressed locally. For the individual patient the NHS has much to learn from local government that focuses much more on the individual citizen.

As ever adaptive leadership. PCNs must be regarded as a network of organisations and people that must be maintained and nurtured to guarantee localness. At the other end of the size scale multi providers and commissioners to work cohesively together in partnership to serve their larger community. As the concept of a complex adaptive systems is fully grasped a new governance is essential, a collaborative governance underpinned by relationship governance. Not the compliance based top down traditional NHS governance, but one defining relationships, behaviours and responsibilities. The principles and behaviours that underpin any successful alliance, such as ‘no disputes’ [which is not to say, no disagreement]; a ‘best for citizens’ rule; the need to work in good faith and the critical importance of trust; and the necessity for transparency and for any alliance to be transparent to its population. Contracts are necessary but should underpin relationships, not define them.