Matthew Swindells: The future of commissioning

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  • Posted:Wednesday 11 October 2017

Matthew Swindells, National Director, Operations and Information, NHS England discusses the role of commissioners in delivering sustainability and transformation partnerships and creating accountable care systems.

This presentation was filmed at our conference, Future of commissioning, on 11 October 2017.


The challenge that we need to face, now the NHS has a whole is facing is the growing demand and financial circumstances that we all find ourselves in, maybe 30% of the patients in an acute hospital shouldn’t be in hospital and maybe half the patients who turn up to an A&E department actually didn’t need to come to an A&E department, they needed care somewhere else and according to the Royal College of GPs, 27% of the patients who see a GP didn’t need to see a GP, they needed some sort of care, and what you get is a sense that we have to do a channel shift, that this isn’t just about being smarter in individual silos, it’s about moving all of the pieces one step to the left.  It is clear that this isn’t an institution by institution problem, this is a systemic problem and therefore we need to think about populations and so accountable care systems and SDPs are created to bring together providers and commissioners and the third sector and local authorities and patients and the private sector, to say, what is the best use of the resources that we have and how best can we align them to the needs of a population?  

And I think that’s going to mean some big things for providers and some big things for commissioners and some big things for our relationships with other partners in the wider health and social care system.  

The big challenge for providers needs to be not on their back end, their revenue generation, their income generation.  It needs to be on their service, on unwarranted variation, on mistakes, on errors, on how we spread best practice.  The staffing challenge that we face requires us to have a workforce strategy that runs more than one hospital at a time.  It needs to think about networks of care.  It needs to be thinking about the deployment of a wide range of resources around health needs and no simply about staff in one A&E department while another A&E department 20 miles down the road falls over.  And it seems to me likely that the direction of travel is going to be towards a smaller number of hospital groups that are focussing on what is their standardised operating model?  Why is it that the care in one organisation is better than the care in another organisation and how do I lift and shift that approach to delivering better care, delivering better outcomes from one place to another?  We’re going to need a new mindset for commissioners as well.  

I think that things like population segmentation, the alignment of clinical pathways, the building of integrated clinical networks, oversight of service redesign, performance management of itself and the wider system, the application of financial control over the whole of the envelope.  We call it commissioning but it is actually management, and that the closer we bring commissioning to a partnership for the delivery of an SDP or an ACS the less the split of this is a handoff around a transaction becomes relevant and the more we start to say the building of an SDP is the joint working of the leaders of the whole of the system to say what can we deliver for the money that’s available and how do we optimise our impact on the health of a population?  How do we move towards the 30-50,000 populations, the network of GPs, who might be one very large practice, but could just as easily be small practices working together in order to ensure a comprehensive service for a population?  We talk about 30-50,000 as the building blocks of a provider landscape that runs through community services and mental health to the acute trust and actually this is one design conversation, and it’s not mediated by a contract, it’s mediated by a management decision on how do we improve the care for stroke patients or diabetic patients or young children with obesity.  But I think there is a layer that sits above SDPs and ACSs, which is effectively the management of a local mandate. 

So, NHS England takes a mandate from the Department of Health, this is what you have to deliver for the £120 billion we’ve given you.  Somewhere we need to have that being passed off to an accountable care system which says, here is your £5 billion or £2 billion or whatever your patch is, now this is what is expected from that, and then how do we set how we hand off targets and priorities and outcomes, whether it be improvement of the management of HbA1C or the reduction of obesity in a population, and then there’s a need for a, both a performance management relationship but also an improvement in innovation relationship.  How do we improve spread across the country?  We face real and present challenges which in my view, can only be dealt with at a place based level with people parking their egos at the door and actually working on what is the solution for the pot of money that we’ve got which best gets us to the outcomes we need and we need to do that, in an environment where there is absolutely no possibility that in the next few months we’re going to get a new Health Act.   

So we need to be able to be grownups about being the leaders of this system on behalf of the public and make stuff work despite the help we’re getting.  

Thank you very much.