This constant cycle moves between primary care-led budget-holding and commissioning in larger, centralised groups or specialist networks. With each set of reforms, productivity is negatively affected; important relationships built up between commissioners, local authorities and providers to drive innovation are undermined; and top managerial talent leaks away.
For the coalition government, deciding to undertake another major overhaul of NHS commissioning was not a decision to take lightly. Nevertheless, it pressed ahead, moving budgets and commissioning decisions into the hands of GPs – now clinical commissioning groups – to ensure that the process is professionally driven by those who know the needs of their patients. Swathes (about 45 per cent) of 'unnecessary management bureaucracy' could be cut by replacing primary care trusts and strategic health authorities, with single NHS Commissioning Board to set quality standards and manage commissioners based on their outcomes. From the outset we were told it would be different this time: that a streamlined approach to NHS commissioning would be set in place and that commissioning would be 'turned on its head' so that local clinicians could drive the process on behalf of patients.
How things change. Today – as the NHS Commissioning Board commences a period of shadow running before becoming fully operational – the emergent commissioning architecture has become far more complex. Between the NHS Commissioning Board at one end and the clinical commissioning groups at the other, the variety of commissioning support agencies is growing exponentially to include: regional arms of the NHS Commissioning Board; PCT clusters; commissioning support units; clinical senates; specialist clinical networks; health and wellbeing boards; and clusters of clinical commissioning groups. You could easily add the likes of Public Health England; local health improvement boards' regulators (like Monitor and the Care Quality Commission); the National Institute for Health and Clinical Excellence; local GP councils; third sector suppliers; and individual practices enrolled as clinical commissioning group members to this list. Patients, too, are becoming commissioners as they begin to wield personal health budgets.
This array of commissioning stakeholders is in danger of creating confusion – who, for example, should a large mental health trust turn to over matters of service redesign to bring together mental and physical health services? Clinical commissioning groups – as the statutory commissioning authorities – might be the obvious answer, but just look at how many agencies they will have to account to. They will need to balance the concerns of their GP members; other groups; the local health and wellbeing boards, and the NHS Commissioning Board. This is surely a recipe for conflict. While clinical networks, clinical senates, PCT clusters and commissioning support units are primarily designed to facilitate these discussions, it is more than likely that they will also wield a degree of commissioning authority and influence.
We shouldn't really be surprised at the growing complexity of NHS commissioning. A year ago I considered how commissioning will have to operate at multiple levels depending on the services that are being commissioned and how the 'intelligent commissioner' needs to be a highly effective networker to manage multiple relationships. Though painful, the system is recalibrating itself in recognition of this. Indeed – just last week – the Department of Health produced its vision for the development of commissioning support in the NHS, which attempted to articulate how these complex relationships might work. For many, however, the document has brought further confusion as to whether clinical commissioning groups will be allowed to develop their own plans for commissioning support other than through PCT clusters. The irony in all of this is not just that they are clearly reinventing the wheel, but that the process itself has led to the centralisation of commissioning, as PCT clusters appear to be controlling many clinical commissioning groups while the NHS Commissioning Board takes a firm grip on proceedings at every level. Hardly a case of 'turning the NHS on its head'.