The purchaser–provider split has been dissolving since the NHS five year forward view was published in 2014. First ‘new models of care’ brought together organisations from different parts of the health and care system to test out new ways of delivering care in a more coordinated way; now integrated care systems are bringing together commissioners and providers to plan and pay for services more collaboratively.
These changes are happening in spite of the legislative framework of the NHS, rather than because of it. Arguably the Health and Social Care Act 2012 strengthened the purchaser–provider split by enshrining elements of the internal market in legislation. That’s why NHS England and NHS Improvement recently published proposals for new legislation designed to make implementation of the NHS long-term plan – which focuses on collaboration rather than competition – easier and faster. One example is their proposal to abolish the requirement that all NHS contracts above a certain threshold are put out to competitive tender.
This week we publish a new report by Ben Collins that examines the use of incentives in the NHS (a key element of the purchaser–provider split and the competition-based internal market). The report – which, despite its technical-sounding topic, is a genuine page turner – describes how successive governments have been convinced that financial incentives can create a self-improving NHS, but their attempts have failed. It asks why we think the new payment models that are being developed to support integrated care will be any different. The report calls for urgent reform (and simplification) of the system for paying and contracting services in the NHS, to free up local systems to focus on improvement.
But what does this mean for commissioners who – despite the calls for reform – still need to get on with their jobs? Whatever changes happen to the functions currently referred to as commissioning over the next few years, most of the key tasks involved (which are often summarised in the commissioning cycle) will continue. It may be that providers start to take on some of these activities or that new organisations – like the ICSs – become responsible for them, the way some activities are done may change, and some may no longer be relevant; but every health system (including those, like Scotland, that do not have a purchaser–provider split) needs people to assess local needs and then plan, develop and monitor services – whether or not we call them ‘commissioners’ and whether or not they work for ‘commissioning’ organisations.
There is a risk that as local systems develop new structures and systems for planning care they throw the baby out with the bath water. One example is clinical involvement – clinical commissioning groups (CCGs) may not have perfected clinical engagement but many have gone further than before in engaging GPs in local decision making. New structures need to build on this and involve an even wider group of professionals and patients. Another example is performance management. CCGs may not have wielded much power over big acute trusts but while it’s important that providers and commissioners collaborate to promote improvement across systems, there still needs to be some grit in the system to ensure providers are held to account.
At a time when commissioning is undergoing so much change, we are launching a new project that aims to support local systems as they take key decisions about the functions currently known as ‘commissioning’. We will map out how key planning or ‘commissioning’ activities are conducted in the NHS and elsewhere, who conducts them and what the evidence tells us about what works and what doesn’t work for each. We will draw on learning from 30 years of commissioning in England, and planning in other advanced health systems, including Scotland. And the project – which will run throughout 2019 – will include field work with innovators.
If you are working in a system that is making changes to the way it conducts commissioning activities like strategic planning, service development or monitoring and evaluation, we’d love to hear from you. We’re not only interested in what you’re doing, we’re also keen to hear how you decided on the new approach. Our aim is to present evidence, learning and case study examples to help to inform thinking in local systems and at the centre too.
To find out more about the project and how you can get involved, email Ruth Robertson.