Commissioning: a rookie’s guide

1 Nov

Commissioning: what does that word mean to you? I had no idea  when I first came across it but it sounded pretty dull. Turns out it’s not dull at all, in fact it’s possibly one of the most interesting aspects of a healthcare system if you’re interested in that kind of thing (as I am), particularly if you are in the UK. As to why that’s relevant, onwards we go…

So what is it?

Commissioning is all about buying the right healthcare services for your population. In addition to purchasing responsibilities, the use of the word “commissioning” as done in the UK indicates that the role also involves extensive strategic planning and setting priorities etc.

It is obviously massively important in any healthcare system but in the UK this concept of commissioning has undergone multiple costume changes in the last two decades, making it a rather “hot” topic.

What’s happened in the UK?

A lot actually. The following is mostly based on the chapter of Commissioning written by Judith Smith and Natasha Curry, at the Kings Fund.

The first most important reform affecting commissioning was Thatcher’s New Public Management reforms in the early 1990s. It was the birth of commissioning if you will, as it was formally split from healthcare provision. It was supposed to overcome the information asymmetry that favoured providers.

Then in the early 2000s, new Labour came in and made PCTs in charge of commissioning. As Smith and Curry have written:

“The PCT model was predicated on a belief that strong local commissioners would be able to assume financial risk for a defined geographic population, providing community health services, and buying other services”.

In essence, this regional level of commissioning meant that the financial risk of making sure that the population’s needs were being met appropriately was divided up between 303 statutory bodies, making it less risky for central government, which was paying all these PCTs out. Having relatively decentralised regional level services meant that there was also the opportunity for individual PCTs to shape their commissioning on grounds of their particular population’s needs.

The Labour government also brought in practice based commissioning, a voluntary scheme whereby a GP practice or a group of practices could ask their PCT to delegate a budget to them. This meant that the GPs themselves could plan and commission a defined set of services for their patients, either from themselves or other providers. The GPs were allowed to keep the financial savings that were made for other services, which acted as an incentive to prevent overspending. As it was voluntary however, some argue that it led to a “two tier service” for patients, depending on whether their GP practice had chosen to get involved in  commissioning or not. There is also limited evidence that PCTs and PBC has improved health inequalities and efficient use of resources. Also, no-one in the public knew about commissioning; this low profile and lack of legitimacy meant that there was weak downwards accountabiltiy and little PPI, an important aspect in all strands of healthcare.

Now fast forward to 2013: the Conservative government are again in power, and both PCTs and practice based commissioning has been abolished. So what remains? New bodies called clinical commissioning groups (CCGs) have been set up to take over the responsibility of around 60% of all commissioning done in the NHS. The NHS Commissioning Board (NHS CB) remains responsible for commissioning specialised services. It is hoped that as CCGs have lots of clinical representation (nurses, clinical directors, doctors, GPs), they will know best to align financial risks and incentives and keep a control on service provision.

The problems

There are several major challenges that face CCGs once they get their acts together. Alongside coping with system-wide changes to public health, the HPA, social care etc., they must focus on maintaining and improving population health in the face of budget freezes and further economic challenges. That’s the most obvious issue I guess.

Secondly, as GPs now have a major role in where resources go, there could be a shift in patient doctor relationships. GPs who sit on CCGs may not have the time and/or skills for effective commissioning. Also, for example if you’re a GP whose CCG has just made a decision on shaving off the budget for COPD clinics or something, talking to all your COPD patients could get a little awkward knowing that you’ve contributed to that decision. In all honesty I’m not sure to what extent this could be a problem as I would have thought that the majority of patients wouldn’t know what their GP did outside of their office.

Thirdly, the key word of the Coalition government’s approach to Healthcare (and everything else) has been “COMPETITION”. Simultaneously however, there is an increasing movement towards integration of services, which has a strong and growing evidence base. How these two ideas (which seem at odds to one another) will be balanced is something I’m sure a lot of CCGs are still worried about 7 months down the line.

Opportunities

It’s not all bad news however, and CCGs have great potential to do good. Merging PCTs may make it easier to influence large providers. They also offer a new face of commissioning which could be more accessible to the general public. With patient and public involvement (PPI) being so important, this has great potential. Also the shift in focus from process led frameworks to an outcomes framework may be beneficial.

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