Is strategic commissioning the future for the NHS?

The current system of commissioning and providing health care in England is evolving in response to growing financial and operational pressures, and the new care models being implemented in the wake of the NHS five year forward view. Of particular importance is the requirement on NHS organisations to work together to develop sustainability and transformation plans (STPs) in the 44 areas of England designated for this purpose.

The work being done to develop STPs is a practical example of the interest now being shown in place-based systems of care. The Fund has argued that place-based systems offer promise by enabling commissioners and providers to collaborate in responding to the pressures they are faced with, and agreeing on how services should be transformed to better meet the changing needs of the population. We have also argued that within these systems commissioning should be seen primarily as a strategic function that brings together scarce expertise with much greater integration of commissioning, both within the NHS and between the NHS and local government.

Strategic commissioning will require thoughtful evolution towards a system in which the clinical expertise and knowledge of clinical commissioning groups (CCGs) are retained, and where NHS commissioning is based on footprints much bigger than those typically covered by CCGs today. This has been happening for some time in areas such as north-west London, Staffordshire and Greater Manchester, and is being extended to other areas as the STP process gathers momentum. In the Fund’s view, strategic commissioning encompasses the funding and planning of services in addition to holding providers to account for the delivery of agreed outcomes.

Strategic commissioning is quite different to how commissioning is currently understood and practised in the NHS. It will no longer entail detailed contract specification, negotiation and monitoring or the routine use of tendering. Instead, the focus will be on defining and measuring outcomes, putting in place capitated budgets with appropriate incentives for providers to deliver these outcomes, and using longer-term contracts extending over five to ten years. This will reduce transaction costs and free up resources to invest in improving health and care.

New care models being implemented in different parts of England are beginning to blur the distinction between commissioning and provision. More integrated models of care, such as primary and acute care systems and multi-specialty community providers, are taking on some commissioning functions, as when lead providers subcontract with other providers to deliver the requirements specified in their contracts with NHS and local government commissioners. This is simultaneously reducing and extending the role of CCGs as they delegate some of their functions and assume new ones in partnership with other CCGs, NHS England and local authorities.

This is one of the reasons why integrated commissioning between CCGs and local authorities through health and wellbeing boards and other means is likely to become more important in future. The shifting sands on which CCGs rest point to a future in which some forms of commissioning will remain local, others will become more strategic and yet others will migrate to emerging integrated care models.

Our forthcoming report, based on a four-year research project carried out with the Nuffield Trust, will set out in more detail how clinical commissioning has evolved up to now and what it will need to do to adapt and change in the future.

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#547690 SGM

I think this direction of travel is welcome and suspect it may go towards having elected Health Commissioners being either a function of the Mayor's office or something akin to police commissioners.

I would disagree with the assertion that 'It will no longer entail detailed contract specification, negotiation and monitoring' - for the first two I would hope there would certainly be a robust value for money process, albeit much less often with longer term, system wide contracts.

#547693 Pearl Baker
Independent Mental Health Advocate and Advisor/Carer/ Trust Governor

I have worked in the area of Mental Health for thirty years, unfortunately it is evolving into one 'almighty mess' what was actually wrong with the old system of 'Care Manager Co-ordinators' are essential for those with LTC. The only improvements I would make is with the Care Manager Co-ordinators, they need to be Multi Tasking experienced in Health & Social Care, Legislation/Laws... A 'Care Plan' meeting would identify the 'GAPS' ie No Personal Budget, No Independent Advocate to support their views, their 'choice' to chose the own Health & Social Care Providers, Emergency 24 hour contact number, experienced in Mortgages, travel expenses if on Income support, claims from Hospitals, or other visiting other agencies involved in your health & social care treatment.

Day centre, rehabilitation services are essential if the Patients has any chance of improving their Health & wellbeing.

The system of communication between agencies is too fragmented, 'Joint health and social care funding' is essential.

CCG are NOT up to the 'job' they are mainly a group of GPs not experienced in Management particularly Finance. They discriminate funding via the 'Better Care Fund' Mentally Ill get almost nothing in my area of West Berkshire, they think 'Talking therapies' is the answer to all, unfortunately those suffering from a 'severe and enduring mental illness' could be 'damaged' by those recruited to 'talk' to the worried well.

To have a 'joined' up system that includes health and social care and the finance based on Population/identifying those suffering from a LTC is essential.

I have spoken to many colleagues all are in agreement it starts to go wrong from the GP end.

I am NOT in agreement that the idea that a 'different' group of individuals and NOT the GP could take over the treatment plan of those severely mentally ill, and that you would NOT necessarily see the same people is actually degrading, and unacceptable.

I fail to see why everything has got so complicated. the patient, carer, Consultant, (Care Manager Co-ordinator) with their knowledge should be qualified enough to understand the system, reporting back to a CENTRAL Point when they identify a 'gap' in the system.

Why am I so busy? because the system is in chaos, and I am left contacting a number of agencies responsible for their client, only to find the 'Care Manager Co-ordinator' has gone on holiday, and left the patient and Carer in LIMBO.

#547695 Ed Macalister-Smith
PCT CEO retd

Evolution is an interesting term to use here, given that commissioning has already been there...

Remember World Class Commissioning 10 years ago? Some people were sceptical, but it was exactly the right vision to have, and Chris repeats that here. It encompassed system leadership and partnership working, and was mostly not about the detail of contract specification and negotiation.

Back to the future anyone?

#547696 James Peskett
Healthcare consultant
PA Consulting Group

Chris - you are right, commissioning is changing, a point I made in my own article, Quantum Leap PA's recent survey of 100 CCG leaders, with the HSJ, suggests commissioners are moving away from more traditional market mechanisms, towards more novel contract and payment mechanisms. Of particular interest, was CCG leaders' preference for accountable care systems over accountable care organisations. This suggests CCG leaders believe their organisations still have a key role to play in commissioning in the future, but the creation of new organisations is less important than improving collaborative relationships.

#547701 Poppy
Human being
Human Race

Change the bloody record!

#547702 Clive Bowman
City London

Accountable commissioning this missing link perhaps

#547719 Peter Rogers

Perhaps we could call the 'new' strategic commissioning bodies Area Health Authorities?

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