Commissioning - Health Committee Contents


Memorandum by Dr Pauline Brimblecombe (COM 116)

COMMISSIONING

"World-Class Commissioning": what does this initiative tell us about how effective commissioning by PCTs is?

  The vision of World Class Commissioning is for the available resources to be used as effectively and fairly as possible to promote health, reduce health inequalities and deliver the best and safest possible healthcare. Prior to the WCC initiative PCTs delivered services on a historical basis rather than a public health needs assessment. Delivering on demand rather than need has produced wide variations and contributed to some of the health inequalities. The fact that PCTs have not fulfilled their commissioning role to date is unsurprising given the emphasis of the health reforms on the provision side and on "patient choice". Despite the emphasis of WCC on priority setting, commissioning decisions are still very much determined by government targets and other "must-dos" such as NICE decisions and SHA dictat.

The rationale behind commissioning: has the purchaser/provider split been a success and is it needed?

  The purchaser/provider split has educated the provider organizations that their role is to deliver services that are needed rather than on what they have historically delivered. This has been and continues to be a difficult message for acute trusts to assimilate. The bulk of health expenditure is spent in the acute sector and yet delivers care to only the top 10% of the health pyramid. Despite the wish to move funding from the acute sector into the community, the power of acute trusts and emphasis from government, (despite its rhetoric) on acute services, care in the community is mainly theoretical.

Commissioning and "system reform": how does commissioning fit with Practice-based Commissioning, "contestability" and the quasi-market, and Payment by Results?

  The logic of PBC is sound. The role of the GP is not only to deliver personalised care but also to focus on the total needs of its registered population. PBC falls down in that the population and therefore resources are too small to manage risk adequately and the administration costs duplicated. This could be improved if practices worked in localities or federations around a more sustainable population c70,000.

  Contestability and the quasi-market rely upon knowing what outcomes you want and being able to identify the available resources. The tendering process should deliver more cost effective services but it is time consuming and only suitable for large contracts. PBC needs a speedier more flexible approach to implementing change.

  PBR was helpful initially to focus providers on their activity. However now it stands in the way of real service transformation. PBR focuses on activity not outcomes and does not incentivise innovation. It makes collaboration between providers difficult and basically encourages the status quo.

Specialist commissioning;

  To look at specific areas of specialist care with a large population makes sense. However it can also lead to loss of ownership by the PCTs if they have no input into the process and if their own identified priorities are subsumed.

  For example the East of England SHA specialist-commissioning group for IVF provision has imposed its decisions on all PCTs. The dictat to provide all eligible couples with up to three fresh IVF cycles diverts scare resources from local PCT priorities and with no ring fencing of the budget allows no account of local circumstances

Commissioning for the quality and safety of services.

  This should be the number 1 priority but in reality is often superceded by affordability and the choice agenda. By more involvement of clinicians and patients in decision-making this could be changed. This is political, as most GPs and probably patients would rather sacrifice choice for an affordable quality and safe service.

  Personal view of why PBC has so far failed to deliver its potential

    Failure of clinicians to understand what commissioning means—and why should they as their training is in delivering the best care for the person in front of them? With the greater acceptance of the need for "distributive justice" this is improving—and as clinicians begin to understand the problem they come up with the solutions. GPs are nearly there; acute clinicians haven't even reached the starting blocks.

    Disempowerment of the GP—by government, SHA, PCTs, acute care consultants. Good management is about improving performance through support and education- it is not about taking over. In any other profession a consultant advises and hands back the problem—they do not take over the problem.

    The blank cheque phenomenon—when a GP makes a referral they have no idea what the final cost of this transaction will be. Financial control is lost as soon as the patient enters secondary care.

    Lack of performance review—without feedback on which to reflect—behaviour change cannot occur. Comparative data stimulates professional pride to improve—league tables work.

    Medicalisation of health—the public have been medicalised into patients. There is a need to take back responsibility for their own health, learn to rationalise risk, and work in partnership with health professionals.

    Managing expectation—too much political fuelling of public expectation and emphasis of rights over responsibilities. Public say they value the NHS yet there is much wastage of resource especially medications and missed appointments.

    Death—there needs to be a recognition that death is a natural inevitable outcome of life. Managing a good death is as important as prolonging a poor quality life.

January 2010








 
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Prepared 8 April 2010