6 HOW THE GOVERNMENT HAS RESPONDED
TO WEAKNESSES IN COMMISSIONING
133. In chapter four we outlined the weaknesses in
commissioning. The Government is well aware of these weaknesses
and in recent years has begun trying to address them. Its main
attempts to do so have been through:
- World Class Commissioning (WCC)
- The Darzi Reforms (CQUIN, PROMs, Quality Accounts
and Never Events)
- Framework for External Support for Commissioning
(FESC)
In this chapter we discuss these policies.
World Class Commissioning
134. In 2007 the Government introduced its World
Class Commissioning (WCC) initiative, which seeks to make commissioning
more professional and improve the competencies of NHS commissioners.
Its very existence is an admission that commissioning has been
a weak link in the English NHS and a great deal rides on its success.
135. The WCC programme includes four strands:
- A vision for World Class Commissioning;
- Eleven Organisational competencies;[158]
- An assurance system to hold commissioners to
account and reward performance and development;
- Support and development tools.[159]
136. The WCC vision and competencies are supported
by a commissioning assurance system which is an annual process
that reviews PCTs' progress towards achieving better health outcomes
for their populations and provides a common basis for agreeing
further development.
137. Mark Britnell, the architect of WCC at the Department,
explained:
I wanted to create something which had the discipline
and rigour of the foundation [trust] assessment exercise and the
stretch that gave people the ambition to raise their sights [...]
we defined these 11 competencies—which I do not think anybody
really disagreed with. It might strike you as slightly odd—it
did me coming into the department—that no-one had defined
what good commissioning was in 20 or 30 years.[160]
138. The first year assurance results were published
in March 2009. At the end of WCC assurance Year 2 (July 2010),
nationally calibrated PCT results will be published by the DH.
As we have already noted, the process has uncovered weaknesses,
particularly in the commercial aspects of commissioning.[161]
139. WCC will require a very significant change for
most PCTs. Many of the aspirations of WCC are supposed to have
applied to the NHS over the last 20 years, but few have been achieved
systematically throughout the NHS in England.[162]
The Minister of State acknowledged the programme's importance:
we need to increase the power of the purchaser
so that the purchaser is better able to represent the taxpayer
and the patient, and better able to manage the way in which NHS
funding is spent, and better able to counterbalance the provider
interest in this equation. All of that is around improving the
quality of commissioning—and that is why World Class Commissioning
as a process is so important.[163]
140. While, as we have seen, the first year assessment
exercise demonstrated the weaknesses in the system, in subsequent
years PCTs are expected to progress rapidly. DH officials told
us that they were in a more decisive phase with serious action
being taken against PCTs who have not improved enough.[164]
141. The WCC initiative was widely welcomed and seen
as helping PCTs to focus their minds on what needed to be done.
The Chief Executive of Northamptonshire PCT found it helpful to
show him where he needed to be going.[165]
Monitor argued that WCC fits well with commissioning for quality.[166]
142. However, concerns were raised by Monitor
and others. The Royal College of Midwives stressed that the developments
of commissioning were very recent and there was a lot of ground
for commissioning bodies to make up. It was too early to judge
whether it will be successful or not:
These developments are however recent, especially
when compared with the developments on the provider side. This
means that commissioning organisations are now playing catch-up
and it will take some time before all the benefits associated
with the recent reforms become apparent. [167]
143. The key question is whether WCC will be enough
to address the enduring weakness of commissioning. Although WCC
seeks to bring about a "step change" in the capacity
and capability of PCTs to act as effective commissioners, some
witnesses thought that the enduring weakness of commissioning
was unlikely to be addressed by WCC alone.[168]
144. Health Mandate drew attention to the fact that
approximately a third of PCTs have opted to focus on more "indicators"
where their performance is already better than the national average
than where it is worse. This calls into question the extent of
the ambition of some PCTs and casts doubt on whether the WCC agenda
will in itself address inequalities of performance.[169]
This would imply that PCTs are "gaming" the assurance
system.
145. There are further concerns about the assurance
process itself. Professor Ham stressed that better outcomes of
care and better value for money were not inherent in the assurance
process, and thus queried whether assurance was asking the right
questions.[170]
146. The Royal College of General Practitioners felt
that WCC needs to be properly scrutinised by Strategic Health
Authorities (who have a performance management role in respect
of PCTs), otherwise it risks being "a paper-based exercise".[171]
The results of the NAO survey suggested that PCTs were concerned
that the assurance process could become a "tick box"
exercise, taking a long time to complete and distracting staff
from their core jobs.[172]
Survey respondents also raised concerns about the balance between
the assurance programme and the development programme within WCC.
147. The King's Fund also made the really important
point that even if WCC is successful it leaves unaddressed the
incoherence in system reform, as we discussed in the previous
chapter:
It is not that the policies themselves do not
"fit" with WCC. But rather that the structures and mechanisms
within which they are operating are working against the aspirations
of WCC.[173]
148. Ridiculous though the term is, much of the
World Class Commissioning initiative is unexceptionable. It is
clearly too early to judge the success of WCC but note there are
serious concerns about the capability of PCTs to make the huge
step changes required. We recommend that the Care Quality Commission
uses the eleven competencies of World Class Commissioning to judge
PCTs.
149. We are concerned that PCTs might be too complacent
to make the necessary improvements. A survey we commissioned from
the NAO revealed a remarkable degree of misplaced confidence on
the part of PCTs about how well they think they are doing.
150. It is not clear to us that WCC is going to
address the lack of capacity and skills at PCT level and weak
clinical knowledge. Furthermore there are concerns that WCC will
be no more than a "box ticking" exercise whereby people
expend a lot of energy merely demonstrating they have the right
policies in place, rather than actually transforming patient outcomes
and cost effectiveness.
151. WCC does not address the systemic imbalance
of power between commissioners and providers. The DH has developed
other policies that do seek to address this, to which we now turn.
Darzi Reforms
152. Lord Darzi was commissioned by the previous
Secretary of State to undertake the Next Stage Review. He published
his final report, High Quality Care for All, in 2008.[174]
As part of his aspiration to bring about better quality of care
he proposed giving PCTs a number of means whereby they could more
effectively exert pressure on providers to improve their services.
These are forms of "pay for performance" (P4P) or "value-based
purchasing", an idea which has been developed in the USA.
We examine these below.
CQUIN
153. The Commissioning for Quality and Innovation
(CQUIN) framework, which was launched in April 2009, facilitates
providing financial incentives payments for good quality care.
The Minister of State told the Committee:
CQUIN is going to be increasingly important,
particularly to encourage stretch and innovation. It will give
a greater degree of negotiating power to PCTs.[175]
154. However, the Committee received evidence of
concerns. Professors Bloor and Maynard have argued that it is
not yet clear whether incentive schemes will result in improved
patient outcomes and justify the cost of implementing them. Evidence
for US incentive schemes is weak and the impact of the new scheme
in the English NHS is not predictable:
Experience from the US suggests that a balance
needs to be struck between the motivational effects of potential
penalties and the possible costs of destabilising organisations.
In addition, if penalties are a real possibility and are on occasion
levied, their motivational effects are likely to be short lived.[176]
155. Witnesses also expressed concerned that CQUIN
would destabilise providers if it were successful, particularly
as from 2011 the potential income losses will be 10% of revenue.
Mr Parkes told us:
I just think that there is 1.5% in CQUIN and
an expectation of 3.5% efficiency. We just need to be careful
that we are not destabilising our providers but getting the right
focus on improving quality.[177]
156. It was also thought CQUIN could lead to the
worst of all worlds, increasing tensions between commissioners
and providers while achieving little. Professor Bevan told us:
There obviously is a conflict here between paying
primary care trusts a fair share of the NHS budget for their population
and paying providers for the volume of services that they supply.
There is no guarantee, of course, that these two will equate,
and as we are entering very hard times in the NHS, it is difficult
to see how these tensions will be resolved. If you look at the
evidence on pay for performance, which is very fashionable in
the United States, there is very weak evidence of it having been
an effective innovation.[178]
157. Despite the misgivings that some people have
about CQUIN, it is regarded by others as having significant potential
to improve commissioning. When we considered the Next Stage
Review we supported using financial incentives to improve
quality but recommended that the Department "proceed with
caution", piloting and rigorously evaluating all such schemes
before their adoption by the wider NHS.[179]
158. The Government stated in its response to our
report on patient safety:
The CQUIN framework was launched in April 2009.
Although it is not being formally piloted, the first year is very
much regarded as developmental and the Department is working closely
with NHS partners to share learning and to inform how the framework
develops in future.[180]
It transpires that evaluation will be very difficult
because the DH has allowed for local variation in the implementation
of CQUIN. As we stressed in our report on health inequalities,
evaluation of policy is of the utmost performance.[181]
PROMS
159. CQUIN requires information about quality and
since 1 April 2009 the NHS has become the first healthcare system
in the world to routinely collect patient-reported outcome measures
(PROMs). Hospitals are obliged to measure the physical and psychological
well-being of patients before and after four elective procedures:
hip and knee replacements, varicose veins and hernia repairs.
The resulting data are to be published on the NHS Choices website
and in Quality Accounts (which we discuss further below).
160. The potential impact of PROMs is profound for
patients and the public, as they offer a quantified measure of
both the generic and disease-specific quality of care that patients
receive from the NHS. Patients will have a measure of quality
to help them make properly informed decisions when exercising
their right to choose, and PCTs will have the sort of information
they need to identify the best-performing providers and exert
evidence-based pressure on those who are underperforming.
161. A number of threats to the success of PROMs
have been identified.[182]
A crucial issue is the adequacy of the response rate. Work by
the London School of Hygiene and Tropical Medicine found a response
rate of at least 80% was needed which may be difficult given that
patient compliance is voluntary.[183]
Another problem is that of adjusting PROMs for the longer term
benefits of interventions. Someone who has just undergone a hernia
operation is likely to suffer significant pain immediately after
the procedure, having previously had no pain; but this is not
necessarily a sign of failure as the operation will have removed
the risk of strangulation of the hernia.
QUALITY ACCOUNTS
162. Another way of collecting information about
the quality of care is Quality Accounts. This is an annual report
to the public about the quality of services delivered, which all
providers of NHS healthcare services should produce. The Health
Act 2009, which comes into force on April 1st 2010,
makes this a legal obligation for all providers of acute, mental
health, learning disability and ambulance services to produce
a Quality Account. Further work is underway to develop Quality
Accounts for primary care and community services providers with
the aim of making these obligatory by June 2011.
163. The regulations require providers to submit
a list of the national clinical audits[184]
and national confidential enquiries[185]
that they participated in and a description of the action that
the provider intends to take to improve the quality of healthcare
following a review of the reports.
NEVER EVENTS
164. Never Events are adverse events that are both
serious and largely, or entirely, preventable. The current list,
compiled by the National Patient Safety Agency, is very conservative,
i.e. the events are extremely serious and clear-cut lapses in
patient safety, such as leaving an instrument in a patient or
wrong site surgery.[186]
165. We noted in our report on patient safety in
2009 that the DH had not yet come to a settled view about whether
Never Events would be linked to payment, i.e. whether commissioners
would be able to withhold payment from providers where these events
occurred.[187] Lord
Darzi himself noted misgivings about this idea, with some fearing
that it could suppress reporting of adverse events, running counter
to the NHS policy of fostering an open, reporting and learning
culture.[188]
166. In our report on patient safety we supported
the use of Never Events but said we had "doubts about whether
they should involve a financial penalty", recommending that
this be the subject of a pilot project.[189]
The Government noted this but did not respond directly to it.[190]
167. The Government believes that CQUIN, PROMs,
Quality Accounts and Never Events will improve commissioning,
shifting power away from providers and enhancing the quality of
care. However, we remain concerned that the Government is not
piloting and rigorously evaluating these ideas before implementation,
as we have previously said. The Government's list of Never
Events is too conservative.
Framework for External Support
for Commissioning (FESC)
168. The Framework for Procuring External Support
for Commissioners (FESC) is an initiative that the Government
has undertaken with the stated purpose of helping overcome the
lack of skills in PCTs. The services of 14 private sector companies
have been procured centrally by the DH and PCTs can call on these
for support with commissioning.[191]
This is a way for PCTs to purchase additional skills in services
such as data analysis and contract management. While each company
has been appointed to FESC by the DH it is down to individual
PCTs to decide if they wish to engage one of them, and what areas
they specifically want to commission them to help with. The PCTs
remain the commissioners of local healthcare.
169. In early 2009 the King's Fund conducted a survey
of PCTs in England, examining the use of external support for
commissioning and eliciting views on world class commissioning.[192]
The survey revealed PCTs are increasingly turning to external
organisations, and the private sector in particular, in the attempt
to improve the quality of commissioning.
170. Although using external support is a relatively
recent phenomenon, as many as 76% of PCTs who responded said they
were doing so. The value of these contracts ranged from several
thousand pounds for short-term consultancy work, to several million
pounds in the case of more ambitious schemes. These contracts
are mainly with private sector organisations (40%) or freelance
consultants (30%).
171. FESC provides one route through which commissioners
can engage the support of external organisations. However, the
majority of PCTs in the King's Fund survey opted to use other
channels for procurement—only 27% of PCTs using external
support did so through FESC. Responses indicate that many PCTs
consider FESC to be "inflexible", "too time-consuming",
"cumbersome", and inappropriate for shorter-term work.
172. The FESC framework was designed, in part, to
provide a route through which commissioners could use longer-term
outsourcing. However, the King's Fund survey shows there is little
enthusiasm for this. Instead, PCTs are using external support
as a means of boosting their commissioning capacity and building
up in-house skills. External support is being used across all
stages of the commissioning function, and in particular for the
purposes of developing a strategic commissioning plan, creating
and managing contracts with providers, and reviewing gaps in current
service portfolios.
173. There are seemingly two reasons why PCTs might
bring in consultants.[193]
One is that PCT staff themselves lack skills (capacity), the other
is that staff lack the necessary skills (capability). Using consultants
to supplement capacity raises the question why PCTs are not properly
staffed; bringing in consultants would seem to be an expensive
way of boosting staff numbers. BUPA, one of the FESC providers,
told us that it did bring in important skills which PCTs lacked.
Their submission highlights the need for more emphasis on data
analysis and information acquisition to give managers the tools
they need to manage demand more effectively.[194]
However, UNISON raised concern that the skills being purchased
from external consultants were not being transferred to PCT staff:
The idea is that once companies have been brought
in to advise commissioners they should ensure that there is a
transfer of skills back to the NHS, but it remains doubtful that
this is taking place or will do so in the future.[195]
174. When we tried to find out the overall cost of
FESC, we were initially told the DH could not give us precise
figures of what is spent on external consultants.[196]
Although they subsequently provided the committee with some data
that showed that in January 2010 there were £49.9m worth
of signed FESC contracts.[197]
But this does not equal the total amount spent on external consultants,
as PCTs are not obliged to use FESC contractors and King's Fund
research indicated that often consultants not on the FESC list
were employed.[198]
175. The Minister for State in oral evidence raised
concerns about the expenditure on external consultants:
It is obvious that PCTs should be good at this
stuff, but making them good at this stuff is much more difficult.
I am concerned about the expenditure on management consultants
by PCTs. Frankly, some of it is senior mangers covering their
backs. They get in, they have to make a difficult decision, and
rather than make it, as they are paid to do, some of them are
getting in some management consultants to look at it, paying these
management consultants a lot of money, in order to protect the
chief executive's back. That should not be happening.[199]
The Department has told us that it accepts the need
to collect and publish data on NHS expenditure on management consultants
and will be making this available with effect from a financial
return for 2009-10.[200]
176. PCTs clearly do lack the skills that they
need for commissioning and engaging consultants is one way of
helping to address this situation. However, we are concerned that
FESC is an expensive way of addressing PCTs' shortcomings. The
Minister of State himself expressed concern about the extent to
which consultants are being used. The Department must do more
to determine whether or not the taxpayer is getting real value
for money out of this costly exercise.
177. Whatever the possible benefits of using consultants,
we doubt the ability of PCTs to use consultants effectively.
158 The competences are:
1) Locally lead the NHS
2) Work with community partners
3) Engage with public and patients
4) Collaborate with clinicians
5) Manage knowledge and assess needs
6) Prioritise investment
7) Stimulate the market
8) Promote improvement and innovation
9) Secure procurement skills
10) Manage the local health system
11) Make sound financial investments Back
159
www.dh.gov.uk/en/Managingyourroganisation/Commissioning/Worldclasscommissioning/Vision/index.htm Back
160
Q 83 Back
161
Ev 251 Back
162
Ev 335 Back
163
Q 582 Back
164
Q 602 Back
165
Q 390 Back
166
Ev 236 Back
167
Ev 52 Back
168
Ev 77, Ev 99, Ev 123, Ev 132, Ev 159, Ev 166, Ev 192, Ev 228 and
Ev 283 Back
169
Ev 80 Back
170
Q 522 Back
171
Ev 283 Back
172
COM 119 Back
173
Ev 252 Back
174
Department of Health, High Quality for All: NHS Next Stage Review,
2008 Back
175
Q 587 Back
176
Alan Maynard and Karen Bloor. Will financial incentives and penalties
improve hospital care? BMJ 2010;340:c88 Back
177
Q 379 Back
178
Q 34 Back
179
HC (2008-09) 53-1, para 86 Back
180
Cm 7709, October 2009 Back
181
Health Committee, Third Report of Session 2008-09, Health Inequalities,
HC 286-1 Back
182
Maynard, A and Bloor K. Patient Reported Outcome Measurement:
learning to walk before we can run. J R Soc Med 2010: 103: 1-4 Back
183
John Browne et al, "Patient Reported Outcome Measures (PROMs)
in Elective Surgery": Report to the Department of Health.
London School of Hygiene and Tropical Medicine (2007) http://www.lshtm.ac.uk/hsru/research/PROMs-Report-12-Dec-07.pdf Back
184
National Clinical Audits are intended to engage clinicians in
systematically evaluating their clinical practice against benchmark
standards, to support and encourage improved quality. Back
185
National Confidential Enquiries take anonymised information about
deaths relating to a particular condition or aspect of healthcare
and analyse it to produce recommendations for improved practice.
Back
186
Department of Health, Operating Framework for the NHS in England,
2010-11. From April 2010 no payment will be made were treatment
results in one of the following 7 never events:
1) Wrong site surgery;
2) Retained instrument post-operation;
3) Wrong route of administration of
chemotherapy;
4) Misplaced naso- or orogastric tube
not detected prior to use;
5) Inpatient suicide by use of non-collapsible
rails;
6) In-hospital maternal death from post-partum
haemorrhage after elective caesarean section; and
7) Intravenous administration of mis-selected
concentrated potassium chloride Back
187
Health Committee, Sixth Report of Session 2008-09, Patient Safety,
HC 151-1 Back
188
Ibid., para 212 Back
189
Ibid., para 256 Back
190
Department of Health, The Government Response to the Health Select
Committee Report "Patient Safety", Cm 7709, p 26 Back
191
Department of Health, Framework for Procuring External Support
for Commissioners (FESC), February 2007 Back
192
The King's Fund, Building 'world class commissioning': What role
can external organisations play? Results from a survey of PCTs,
2009 Back
193
Q 396 Back
194
Ev 189 Back
195
Ev 104 Back
196
Q 139 Back
197
UNISON (Ev 104) cites HC Deb, 15 July 2009, Col 545W that £15
million had been spent on FESC Back
198
The King's Fund, Building 'world class commissioning': What role
can external organisations play? Results from a survey of PCTs,
2009 Back
199
Q 589 Back
200
Department of Health, The Government's Response to the Health
Select Committee's report on The use of management consultants
in the NHS and the Department of Health, Cm 7683, October 2009,
p 2 Back
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