The growing complexity of NHS commissioning: a recipe for confusion and conflict?

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It is a truth acknowledged that the English NHS has not yet managed to create a commissioning system, led by clinicians, that wields the power to drive service redesign. Every few years, reforms of the English NHS throw its commissioning architecture into confusion as we search for a better way of doing things.

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'.



Comment date
04 November 2011
i am not sure wether to rejoice or cry. of course what you say is true.
i rejoice because it is about time the gp commisioners, many having no other qualification other than volunteering for the role have checks and balances imposed. I being a biased hospital doctor have found some of them grandiose, reckless and unable to listen to reason. consultations are a joke with not even lip service paid to view of hospital doctors. personal agendas and personal special interests are more important than objectively commissioning a service. my experience anyway. and i am very cynical.

sad though , i think the reforms should have gone even further than currently suggested. if you are taking away a socialised healthcare then why not free up the hospital doctors to provide the best care possible directly , why have an intervening agent as in GP.
then let the hospital doctors be judged on the quality of care they provide and the best survive.
sorry need to have a rant.
what a mess

Nick Goodwin

Senior Fellow,
The King's Fund
Comment date
02 November 2011
Hi Bob,

I think one of the problems is that we always appear to want to solve the issue through commissioning reform rather than focus on what actually matters - reform to the way we actually incentivise service providers.

In recent work we did with HSMC in Birmingham on the NHS reform impacts, both commissioning and choice came out as very weak levers, whilst transactional reform (money and incentives) and governance rules (targets) were what really drove people's motivations (other than good patient care, of course).

Commissioning was beginning to articulate and develop the skills it needed under the World Class Commissioning framework - and there is a real need to invest in commissioning infrastructure and skills rather than undergo a continual reinvention of the wheel instead.

My feeling is we also need to test a very different way of commissioning - actually giving power and responsibility to provider groups (health and social care) directly under risk-sharing agreements with commissioners where outcome measures and incentives are absolutely linked to quality of outcomes (and not simple cost-reductions). This might help give the professional leadership to the change agenda that's required, but also impose a recognition that quality of outcomes and better patient experiences are a collective effort. There are some good examples emerging in the areas of sexual health services, and in the community interest companies that are developing a range of community-based services.

Whatever the solution, we need to break this cycle or commissioning reform and just get smarter at commissioning itself - something that no country with a commissioner-provider arrangement has yet really mastered.

Bob Hudson

Comment date
01 November 2011
Steady on Nick - King's Fund is supposed to be 'establishment'! You are, of course, right. So where do we go next?

Mark Cannon

Vanguard Consulting Limited
Comment date
31 October 2011
You get the prize for understatement of the year "This array of commissioning stakeholders is in danger of creating confusion ". What I see when I study wellbeing economies is that commissioning creates waste. We have a fascination with buying and specifying more and more services and yet report after report shows care in the NHS to be lacking. Something is fundamentally wrong and it is that we do not understand our purpose as an NHS from a users perspective nor take time to understand people in the context of the way they live their lives. Instead we pass people through assessment after assessment, fulfilling our professional or contractual requirements and failing to solve peoples problems when they put their hands up for help. You really couldn't make this up.


Practice Manager,
Comment date
31 October 2011
Each time NHS is reorganised, productivity (measured in terms of effective use of resources and quality of patient care) goes down - it takes about 3 years to get back to where it was.
CCGs are now so bureaucratic that the medical doctors are simply going back to medicine, and appointing managers to run things - funnily enough, often the same managers that used to run things at the PCT. This is necessary because CCGs have to show they have employed/ contracted with ex-PCT staff before they can get authorised (it's called retaining experience), whether those staff were good or bad (which can easily be seen from World Class Commissioning performance - some were terrible!).
So it will cost a lot to stay the same. Well at least the Con Dems have fulfilled their promise not to change anything in the NHS!

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