World Class Commissioning in the NHS

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World Class Commissioning in the NHS Elizabeth
Wade Senior Policy Manager (Commissioning) SSRG
Annual Workshop 20th April 2009
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Overview

• Commissioning in the NHS
• The World Class Commissioning Programme
• What do we know about effective commissioning?
• Priorities for practice development, policy and
  research
• Questions

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What are PCTs?

• Primary Care Trusts (PCTs) are statutory NHS
  bodies
• 152 across country serving average population of
  330,000
• Funded directly by the Department of Health with
  average budget of 527m p.a.
• Accountable to Strategic Health Authorities

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What are PCTs?

• Responsible for ensuring access to health
  services, and improving health outcomes for
  people in their area by
• Commissioning health (and social care) services
• Providing health services (usually community
  health services, sometimes mental health and
  learning disabilities)
• Working in partnership with other local agencies

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What is healthcare commissioning?

• Process by which organisations
• Assess the healthcare/health improvement needs of
  their local population and review how well
  existing service provision meets those needs
• Identify priorities for investment and design
  services/identify opportunities to meet the needs
  
• Acquire these services/create opportunities
  through contracts with a variety of service
  providers including GPs, NHS Trusts, Foundation
  Trusts, third sector and independent sector
  organisations, and partnerships with other
  agencies
• Ensure the services are provided effectively, and
  monitor quality and outcomes

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Who does healthcare commissioning?

• PCTs (hold the statutory responsibility)
• Practice-Based Commissioners
• Specialised commissioning teams
• Local Authorities (through pooled budgets, joint
  commissioning arrangements etc.)
• Care managers/coordinators
• ? Individual service users (patient choice,
  personal budgets)

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Why do we need commissioners?

• To act as an advocate for patients and custodian
  for taxpayers
• To ensure NHS planning and provision is
  needs/demand-led, not supplier-led
• To address the challenge still facing the NHS to
  simultaneously improve
• Service responsiveness and performance
• Patient experience
• Efficiency and value for money
• Public/population health outcomes

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Perceptions of healthcare commissioning

• we have concerns about the implementation of
  the Next Stage Review, which will be the
  responsibility of PCTs, because we doubt that
  most PCTs are currently capable of doing the task
  successfully. As we have noted in a series of
  inquiries, PCT commissioning is too often poor.
  In particular, PCTs lack analytical and planning
  skills and the quality of their management is
  very variable. This reflects on the whole of the
  NHS as one witness told us, "the NHS does not
  afford PCT commissioning sufficient status". We
  consider this to be striking and depressing.
• Health Select Committee - January 2009

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The conclusion of two decades of commissioning
in the NHS?

• Kids, you tried your best and you failed
  miserably. The lesson is, never try

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World Class Commissioning

• Programme developed and launched in 2007
• Significant involvement of/ co-production with
  the NHS
• High profile within the Department of Health
• Assurance process initiated 2008

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The programme
World Class Commissioning
Vision and competencies
Assurance framework
Support and development tools
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Competencies
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Competencies
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Assessed through a combination of. . .

• Self-assessment and certification
• Feedback from partners (including local
  authorities)
• Evidence and data review
• Panel assessment day (including a local authority
  panel member)

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Frequency
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3
1
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1. Locally lead the NHS
2. Work with community partners
3. Engage with public and patients
4. Collaborate with clinicians
5. Manage knowledge and assess needs
6. Prioritise investment
7. Stimulate market
8. Promote improvement and innovation
9. Secure procurement skills
10. Manage the local health system
Source 152 panel scores as of 31 January 2009
(post national calibration)
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The potential impact of WCC

• World class commissioning has the potential to
  deliver more than 25,000 years of healthy life
  expectancy
• if the PCTs that prioritised the following
  outcomes bring their performance up by a
  quartile, it will result in the following impact
  over 10 years
• Smoking quitters an additional 3,600 life years
  gained and 5,000 quality-adjusted life years
  gained
• Diabetes management and stroke care an
  additional 20,000 life years gained and 20,000
  quality adjusted life years gained
• Mark Britnell, Director General Commissioning
  and System Management, DH - February 2009

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What do we know about world class commissioning?

• Experience and available evidence from Europe,
  New Zealand and the US indicates that in no
  system is commissioning done consistently well.
  To be sure, there are examples of innovation and
  good practice in all systems, but equally there
  are examples of the limits to effective
  commissioning and the barriers that have
  inhibited commissioners from negotiating on equal
  terms with providers. Why is health care
  commissioning so difficult? The answer can be
  found in the complex nature of health care and
  the need for commissioners to have a high level
  of technical and managerial skills
• Ham, 2008

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What do we know about world class commissioning?

• The best American commissioning groups have
  concluded that health care is far more
  complicated to purchase than anything else
  Their salary and bonus packages are designed to
  attract the best and the brightest. They require
  excellent data systems analysts and programmers,
  clinical epidemiologists, clinical managers,
  organizational experts, financial specialists and
  legal advisers.
• Light, 1998

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What do we know about world class commissioning?

• Authors in this volume agree that, despite
  prevalent rhetoric, strategic purchasing is not
  in place in many countries and, as a result, the
  impact has been limited
• Overall, the political, technical and
  financial ability to implement strategic
  purchasing is the single most important factor in
  determining its success or otherwise. Most, if
  not all, strategies reviewed here are very
  complex and require a high level of technical and
  managerial skills together with wide ranging
  information systems that are lacking in many
  countries.
• Figueras, Robinson, and Jakubowski, 2005
  

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What do we know about world class commissioning?

• This report into primary-care led
  commissioning clearly demonstrated the link
  between adequate levels of management and
  analytical expertise and the achievement of
  commissioning objectives
• Smith et al, 2004

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What do we know about world class commissioning?

• Existing evidence tells us little about the
  specific mechanisms through which commissioning
  competency does, or does not, lead to improved
  health system outcomes. This does not undermine
  attempts to articulate and develop commissioning
  competency. However, acknowledgement of this
  complexity and ambiguity should be seen as the
  starting point for intelligent discussion of the
  issue.
• Woodin and Wade, 2007

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Development priorities for PCTs

• PCTs need to meet massively raised expectations
  in a very short timeframe, during an economic
  downturn
• Rapid development of commissioning capacity and
  capability is required
• Particular development needs include
• Clinical engagement/expertise
• Communication with the public (to influence and
  engage)
• Up-stream public health (demand management)
• Commercial acumen and skills (procurement,
  contracting, market management etc.)

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Policy priorities

• If WCC is to be successful, we need
• More commissioning-focussed policy, strategy and
  regulation
• Minimal central intervention in structure of PCTs
• More freedoms for PCTs
• Industrial scale interventions to develop
  commissioning organisations
• Significantly improved data quality and
  availability
• Alignment of approach to commissioning in
  different government departments

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Research questions and priorities

• How can we raise the performance of all PCTs, all
  at the same time? Are there models/examples of
  rapid organisational development and performance
  improvement across a whole sector that the NHS
  could learn from?
• What tools, techniques, skills and experience can
  PCTs import from other sectors/countries/industrie
  s, and what is unique to health care
  commissioning?

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Research questions and priorities

• Is it possible to demonstrate a link between
  individual competence, organisational competence,
  effective commissioning, and improved health
  outcomes?
• What are the longer-term implications of a
  commissioning-led NHS (where provision is
  dispersed across a range of competing providers)?
• What are the implications of individual budgets
  and personal health budgets for commissioners?

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The ultimate challenge

• Public service commissioning is essentially an
  exercise in managing scarcity and complexity.
• It will always be the case that some groups and
  individuals in the system will feel that
  commissioning has failed them
• The response of commissioners should not be to
  give up, but to remember their responsibilities
  as advocates and custodians, and to accept that
  world class status may always be elusive

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• Questions/Discussion
• Elizabeth.wade_at_nhsconfed.org
• Elizabeth Wade
• Senior Policy Manager (Commissioning)

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References

• Ham, C. (2008) Health Care Commissioning in the
  International Context Lessons from Experience
  and Evidence. Birmingham Health Services
  Management Centre
• Figueras, J., Robinson, R., Jakubowski, E.
  (2005) Purchasing to improve health systems
  performance. Maidenhead Open University Press
• Light, D. W. (1998) Effective Commissioning
  lessons from purchasing in American managed care.
  London Office of Health Economics
• Smith, J., Mays, N., Dixon, J., Goodwin, N.,
  Lewis, R., McClelland, S., Wyke, S. (2004) A
  review of the effectiveness of primary care-led
  commissioning and its place in the NHS. London
  The Health Foundation
• Woodin, J. and Wade, E. (2007) Towards World
  Class Commissioning Competency. Birmingham
  Health Services Management Centre