A commissioning taxonomy for the NHS in England

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A commissioning taxonomy for the NHS in England

• Judith Smith
• ESRC Managing Scarcity Seminar
• 1 December 2005

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This is the work of a team, funded by The Health
Foundation

• Judith Smith HSMC
• Nick Mays LSHTM
• Jennifer Dixon Kings Fund
• Nick Goodwin - LSHTM
• Richard Lewis Kings Fund
• Siobhan McClelland - Glamorgan
• Hugh McLeod - HSMC
• Sally Wyke - Stirling

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Overview

• Defining commissioning and primary care-led
  commissioning
• What we know from the evidence about PCLC
• Levels of commissioning the taxonomy
• Choosing the appropriate commissioning model
• Challenges ahead for NHS commissioning in England

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The NHS market and a purchaser-provider split

• The terms contracting, purchasing and
  commissioning entered the NHS lexicon in the
  late 1980s and the 1990s
• A purchaser-provider split in an NHS market
• Designed to bring about competition between
  providers, to bring down costs, and improve
  quality and responsiveness
• Health authorities and GP fundholders were the
  two main routes for purchasing in 1991
• A population approach and a patient-focused one
  (Ham, 1996)

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Commissioning

• Commissioning was the term used later in 1990s
  for an arguably more sophisticated and strategic
  activity
• One that encompasses assessment of health needs,
  buying services to meet those needs, and a range
  of strategic efforts to improve health
  (Ovretveit, 1995)

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Primary care-led commissioning

• Term emerged in mid-1990s
• Reflected the emergence of a range of
  commissioning models that sought to involve GPs
  in leadership, planning and decision-making about
  use of resources
• Encompassed fundholding, its alternatives and
  extensions

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Defining primary care-led commissioning

• Commissioning led by primary health care
  clinicians, particularly GPs, using their
  accumulated knowledge of their patients needs
  and of the performance of services, together with
  their experience as agents for their patients and
  control over resources (Smith et al, 2004)

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Why have (or reintroduce) primary care-led
commissioning?

• Rationale that, when given budgetary
  responsibility, primary care providers (usually
  GPs) are well placed to use knowledge of patients
  and services to bring about improvements in
  referred services
• To enable more effective commissioning
• To develop stronger involvement of GPs in the
  management of the health system
• To enable better management of demand for care
• To capitalise on fact that incentives for GPs to
  manage demand/scarcity are clearer than for PCTs

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What do we know about commissioning from the
research evidence?

• Little evidence that shows PCLC, or any other
  approach, to have made a significant or strategic
  impact on secondary care
• PCLC, where clinicians have influence over
  budgets, can improve responsiveness
• PCLC has made most impact in primary and
  intermediate care

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The evidence (2)

• Given a sustained opportunity to innovate, highly
  determined primary care-led commissioners can
  achieve innovation in the local health system
• Primary care-led commissioning increases
  transaction costs in commissioning

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The evidence (3)

• There is no ideal size for a commissioning
  organisation
• A single organisational solution is neither
  appropriate nor possible
• Meaningful clinical engagement is key
• But a balance to be struck with public and
  management accountability
• PCLC (and other commissioning) organisations have
  struggled with public engagement

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The evidence (4)

• Adequate management support is vital and has a
  relationship with outcomes
• Timely and accurate information is crucial, and
  routine data could be used much more
• PCL commissioners need headroom to commission
  according to local priorities
• Relationships with providers need to avoid being
  cosy contestable collaboration
• A degree of stability of organisational
  arrangements is needed

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A commissioning continuum

• No one element of commissioning should be
  considered in isolation
• All part of a continuum from which PCT/board
  chooses according to local health needs and
  service configuration
• Challenge is how to select an appropriate mix of
  commissioning approaches, and having a rigorous
  process for this

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A continuum of commissioning models in the UK

• Level of Commissioning

Individual --- Practitioner --- Practice ---
Locality --- Community --- Region --- Nation
Primary Care Organisation /PCT commissioning
National commissioning
Multi-practice or locality commissioning
Patient Choice
Joint commissioning or health plan commissioning
Single practice-based commissioning
Lead PCT/LHB/HB commissioning
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Evaluating models of commissioning

• Analysis of the service to be commissioned.
  Simple or complex? Level of information about the
  service? Contestable or not?
• Analysis of the context and environment. Choice
  of providers or not? Patients willing and able
  to travel?
• Analysis of the model in relation to assessment
  criteria

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Assessment criteria for models of commissioning

• Ability of the model to
• shape different types of services
• offer a degree of choice of provider,
  contestability responsiveness
• manage budgets and financial risk
• minimise transaction costs
• develop and sustain clinical engagement
• address health needs and tackle inequalities
• improve and govern clinical quality

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Challenges ahead for NHS commissioning in England

• Avoiding the temptation to try and find the
  right size of commissioning organisation
• Working out the relationships between
  commissioning models
• Determining the degree to which the private and
  third sectors should be able to commission (NERA,
  2005)
• Finding the necessary skills and capacity to make
  the commissioning system work
• Governing the commissioning system

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The commissioning organisation of the future

• In a pluralist, yet publicly-financed system, we
  need
• Brain to determine priorities, overall resource
  allocation, service design
• Conscience to assure service quality, manage
  and oversee contracting on behalf of PBCs, govern
  conflicts on interest, secure public involvement,
  assure probity
• Smith and Mays (2005)

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References

• NERA Economic Consulting (2005) Commissioning in
  the NHS challenges and opportunities
• Ovretveit J (1995) Purchasing for health a
  multi-disciplinary introduction to the theory and
  practice of purchasing. Open University Press
• Smith J and Mays N (2005) Primary care trusts do
  they have a future? British Medical Journal 331
  1156-7
• Smith J, Mays N et al (2004) A review of the
  effectiveness of primary care-led commissioning
  and its place in the NHS www.health.org.uk