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How to get commissioning working better: skills, data, subsidiarity and culture |
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Chief Economist, The Kings Fund |
Professor John Appleby |
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To get commissioning working better, we need to address several challenges. First is around the resources dedicated to the business of commissioning. Around 1.4% of the NHS budget is devoted to the mechanics of commissioning, whereas (anecdotally) this figure is about 5-6% in other health systems. PCTs don’t have huge management resources, and have a cap on actual numbers of personnel, which came from one of the regular political drives to slash NHS bureaucracy. So there’s a real lack of resources, in both people and money. Knowledge and skills The second area is around commissioning skills. The Kings Fund leadership development programme is already starting to look at developing commissioning skill sets. World-class commissioning talks about the knowledge and skills needed to do commissioning properly. Do most NHS managers have these yet? In general, I’d say probably not. Third is knowledge – do commissioners have the information they need to do the job? Begging the question, what is the definition of the job of commissioning? I think it’s about improving health and reducing health inequalities. To do that, what information do we need? We need information on the quality of providers, what commissioners get for their money, etc - which we lack in the system, generally. So improving that information is an absolute necessity. Outcomes information and data We’re unlikely to get anywhere without patient-reported outcome measures (PROMs), promised in the current Operating Framework to arrive next year. These can have real impact on service decisions. At Glasgow Health Board in the 1990s, Dr Harry Burns famously got outcome information on the survival rates from four gynaecological oncologists they were buying care from. The information was by consultant, and Harry Burns saw a difference, which suggested that if they bought all their care from the better-performing two of the four, they could save a significant number of womens’ lives a year. But rather than move the contract, he sent GPs a letter with the information. Those GPs changed their referral patterns. That’s what you can do if you have the right information that people trust. The fourth area, the flip-side of knowledge-based changes, is that PCTs may feel held back by the fear of destabilising local providers (who I think may prey on that fear). It’s a very tricky argument, and I’m very sympathetic to PCTs’ position. They’ll undoubtedly draw flak if they move contracts. But they must also consider the costs of not decommissioning less good services, and who bears those costs: is it patient groups who could have had better service, or lives saved, or better quality of life? These are not straightforward decisions. PCTs have to grapple with potentially conflicting goals of equity, efficiency and access. The reality of choice Real choices of provider is not available to PCTs in many parts of the country. So if they lack the crude market threat of taking their business elsewhere, how does the PCT as a commissioner effect change in providers? Hypothetically, if a PCT has information that a local monopoly provider, while not failing, is doing less well than perhaps they could do on quality of care and outcomes (shown by future PROM data perhaps), how can that PCT apply pressure to make the provider improve? It’s not a job for the Healthcare Commission (soon to become the Care Quality Commission, with the inevitable upheaval of that switchover): their job is about regulation and national standards, and having the big stick to close down failing trusts. How can that PCT influence their provider? They could withold payment, which would trigger an interesting response form the local community when the provider then tell them ‘we’re going to lay off doctors and nurses because the PCT won’t pay’. A big PR issue! Another issue, part-related to that PR point, is whether PCTs fear they won’t get SHA or ministerial support if they take decisions which may not, at first sight, be seen as beneficial in some locales. But I think there’s political support for service change, part of the motivation behind the Darzi Review (in part, an unsubtle attempt to say, ‘we will support you, here are some changes, now get on and do them’). Subsidiarity in commissioning Some PCTs could also think about working together in commissioning, on a subsidiarity basis. This might work well in London, where there are 31 of the country’s 152 PCTs. The PCT’s job is to purchase all forms of care on behalf of their population. Maybe we should consider geographically-overlapping PCTs having slightly different commissioning functions on a subsidiarity basis. So one London PCT could purchase cancer care; another emergency care. It would give them a greatly simplified goal and the budget under the principle of subsisdiarity - that is, commission at the lowest level that is effective and sensible, which may, in certain cases mean pan-London or pan-region. In others, it may be sub-PCT. An effective example of this approach was the London Patient Choice project – effectively, a pan-London purchasing project to reduce waiting times. It was given a budget, and had good plans as how to achieve its goals: to identify spare (and largely NHS) capacity in central London; then to identify patients who could benefit from moving; then to phone those patients and offer them the choice. Effectively, it was a capacity-planning exercise. It must be possible to imagine similar approaches – more specialist PCTs, with concentrated skills and resources. Cancer networks and collaboratives already do some of this – networks don’t have money to spend, but they do work closely with PCTs and standardise pathways. They’ve also helped in clinical engagement. The cultural issue There’s also a massive cultural issue for commissioners to resolve – do they really know whose side they’re batting for? There is a tension between vested interests in maintaining the NHS status quo and redesigning services around the needs of patients and residents. Are commissioners stuck in second-guessing the unintended consequences of their decisions? Payment is another issue. Payment by results (PBR) and the unbundling of the tariff present some challenges. While aspects of care remain bundled up in the national tariff, the nature of the payment system may constrain some commissioning decisions. Darzi talks about moving to normative pricing in the tariff, and about quality payments making up perhaps 2% of trust income. When the internal market was in place in the early 1990s, I surveyed the health authorities about the criteria driving their purchasing decisions. Ensuring proximity of services to residents came top. Cost-effectiveness, safety etc. were also of concern, but if commissioning criteria are focused on ensuring that everyone has broadly equal access to everything they may need locally, it’ll be tricky if want to move or change things. We should understand PCTs’ fundamental decision-making criteria in commissioning. They’re trying to satisfy access and proximity, while also wanting value for money, and at the same time urgently having to keep within budget. Some of these goals conflict. How can they resolve those conflicts? Is the answer to create a provider market, and invite new services in? It happens a bit, but so far, not much. Comissioners have a difficult job, with real constraints on their freedom to act in a difficult set of circumstances. Simply blaming PCTs for being institutionalised and unable to react creatively or radically to the freedoms they have been given is too simplistic. |
