Written Evidence from the Centre for Public
Policy and Health, Durham University (COM 140)
NHS COMMISSIONING
1. GENERAL POINTS
Clinical commissioning and/or commissioning for
population health?
1.1 Our comments are focused on commissioning
for population health. A distinction should be drawn between clinical
commissioning/commissioning for patients (or even for practice
populations) and commissioning to promote the health of a local
population. Although the terms are increasingly used synonymously
in the context of the proposed GP commissioning consortia, the
latter has a preventive focus, identifying risks to population
health so that they can be addressed.
1.2 Concentrating on clinical commissioning
(the area with which GPs are most familiar) risks narrowing the
scope of commissioning from a focus on health outcomes for a population
to an aggregate of the clinical needs of individual patients attending
GP practices. Moreover, an extensive lack of fit between GP commissioning
consortia and a local population, as reflected in local authority
boundaries, will make it more difficult to maintain a population
focus, work with local authority partners on developing integrated
services, or assess and prioritise population needs. While a ring-fenced
budget for public health based in local authorities might appear
to address this issue, at least in part, commissioning decisions,
including prioritisation across programmes, involve considering
the balance to be achieved across prevention and treatment and
require public health input: ring-fencing is likely to apply to
only a very limited part of the preventive spectrum and risks
fragmenting a preventive agenda and public health input.
1.3 We agree with the Local Government Association's
view that ring-fencing poses problems in respect of a total or
place-based budgeting approach which starts from the premise that
there should be no ring-fencing.
2. ISSUES FROM
OUR RESEARCH
2.1 The remainder of this memorandum draws
on two recently completed studies supported by the NIHR Service
Delivery and Organisation (SDO) Programme. Both studies were undertaken
between 2007 and 2010 and largely completed before publication
of the NHS White Paper in July. The final reports have been accepted
and will shortly appear on the SDO website. The first study, whose
findings relevant to the Committee's inquiry are reported below,
dealt with public health governance and primary care (Marks et
al 2010). The second study examined the issue of partnership working
in public health and the implications for governance (Hunter et
al 2010).
Key points from Public Health Governance and Primary
Care Delivery: a Triangulated Study
2.2 The focus of the project was the impact
of governance structures and incentive arrangements on commissioning
for health and well being—a question which can also be asked
of the new arrangements as they take shape.
2.3 The study drew on about 100 interviews
with commissioners (including practice-based commissioners), health
scrutiny chairs, LINks and members of the voluntary sector and
allows us to make points related to the following areas: the commissioning
cycle and its impact on health and well being; the involvement
of general practice in health needs assessment, local partnerships
and the preventive agenda; and public involvement in commissioning.
The points below concentrate on aspects which are relevant to
the emerging commissioning landscape.
The impact of the commissioning cycle
2.4 The commissioning cycle begins with
joint strategic health needs assessment (JSNA) of the health needs
of the local population and proceeds through the processes of
prioritisation within resources, procurement of services, and
evaluation of their impact. It should reflect the systematic implementation
of a strategic plan to promote improved health outcomes through
the commissioning cycle.
2.5 Many interviewees argued that World
Class Commissioning (WCC) was premised on an outcomes-based and
public health model. Public health perspectives needed to be included
in each aspect of the commissioning cycle, although some of our
sites were further along this road than others. In many Primary
Care Trusts (PCTs), Directors of Public Health (DsPH) were influential
in strategy development.
2.6 Although criticised on some counts,
our research showed that WCC was considered to encourage an integrated
and systematic approach to the commissioning cycle with PCTs (and
public health teams) involved in each part of the process. As
part of the commissioning cycle, PCTs chose a minimum of 10 health
outcomes of which two, improving life expectancy and addressing
health inequalities, were mandatory. WCC also led to changes in
PCT organisational and governance structures so that they were
better aligned with commissioning responsibilities. Governance
arrangements were therefore being reshaped to ensure processes
were in place to link health needs, strategy development, priorities,
investment and outcomes.
Implications of the NHS white paper
2.7 The NHS white paper contains a number
of implications for the future direction of commissioning and
gives rise to the following key questions:
— While it is proposed that JSNAs continue
under the aegis of the local authority and GP commissioners are
expected to be members of the proposed health and well being boards
(HWBs), governance and accountability arrangements remain unclear.
— How are priorities to be agreed in
these new arrangements and to what degree will they influence
decisions of GP commissioning consortia?
— What is to be the role of public
health directors/teams in GP commissioning consortia- purely advisory
or strategically influential?
— How is the integrity of the commissioning
cycle to be maintained? New governance arrangements should be
assessed for their impact on decision-making in relation to the
preventive agenda, priority setting and working across a public
health system.
— How will health inequalities be addressed
by the consortia? How will we know if these are being considered
or are influencing decision making?
Stewardship of population health
2.8 The first of the three main functions
of PCTs is to engage with the local population to improve health
and well being. This has three elements:
— improving the health status of its
population, and reducing health inequalities, in partnership with
local authorities;
— contributing to well being and sustainable
community development, in partnership with local authorities;
and
— protecting health including through
a robust system of emergency planning.
2.9 Our study showed that leadership of
the Chief Executive, the DPH and the PCT Board was considered
crucial if public health issues were to be reflected in commissioning
priorities. A commitment to health and well being is reflected
in the extent to which commissioning is public health-led, and
indicated in the deployment of incentives and contractual flexibilities
for preventive services, attempts to shift the balance of investment
towards prevention and prioritise longer term health gain. It
is also reflected in the involvement of public health teams with
PBC and in joint commissioning.
Implications of the NHS white paper
2.10 The bulk of the commissioning budget
will be under the control of GP commissioning consortia. WCC influenced
PCT governance arrangements and organisational structures to reflect
the commissioning cycle. It is not clear whether arrangements
in GP commissioning will also reflect this approach.
Involvement of GPs and practice based commissioners
in public health
2.11 Practice based commissioning (PBC)
has largely been focused on demand management. Our study showed
that PBC had mostly been slow to develop, was often poorly integrated
with the commissioning cycle and had limited involvement in the
JSNA, or in health and well being partnerships. Reflecting the
points made above, PBC interviewees articulated tensions between
health care interventions targeted at individuals and health improvement
interventions aimed at populations. It was argued that GPs' training
predisposed them to focus on individual needs rather than on population
needs, the wider determinants of health or where they could make
the greatest impact on health gain for their practice populations,
acting as either commissioners or providers.
2.12 Involvement of practice-based commissioners
in the commissioning cycle was variable, consensus across consortia
could prove elusive, and PBC was often seen as falling outside
the commissioning cycle, unaware of PCT priorities, WCC competencies,
local partnerships, demands on PCTs or QIPP.
2.13 Interviewees raised a number of skills
deficits: practice-based commissioners needed skills in commissioning
on a larger scale and in more complex areas; developing strong
business cases; understanding the larger strategic picture and
the broader health agenda; and commissioning from wider partnerships.
Implications of the NHS white paper
2.14 The limited interest in prevention
amongst PBC in most of our case study sites, in contrast to the
emphasis on managing demand for acute services, may work against
incorporating a preventive perspective across all programmes.
A better developed evidence base on the return on investment from
preventive interventions is important in this respect.
Understanding the role of incentives
2.15 Our study showed not only that health
and well being were not adequately incentivised within the current
health care system but that Payment by Results incentivised the
opposite. Moreover the Quality and Outcomes Framework (QOF) did
not incentivise proactive case finding. Growth money had enabled
some gaps to be filled—for example, Local Enhanced Services
could be used to plug gaps in the QOF.
Implications of the NHS white paper
2.16 While GPs will be incentivised to reduce
acute sector activity, foundation trusts have to produce a surplus.
It is not clear what the incentives will be to encourage partnership
working (previously encouraged through WCC and the Comprehensive
Area Assessment).
Conflicts of interest
2.17 PCTs were mandated to separate their
commissioning from their provider arms. It is therefore ironic
that the well recognised conflicts of interest inherent in PBC,
with GPs acting as both commissioners and providers, are now to
be reinforced. Our study showed that there are many routes for
commissioning health and well being services including GPs, pharmacies
and the voluntary sector. How will conflicts of interest be prevented
by GP commissioners?
2.18 While it has been suggested that large
commissioning organisations can prevent GP commissioners commissioning
services from themselves, what does this mean for services such
as smoking cessation which need to be easily accessible? Moreover,
how will consortia decide whether to commission services from
themselves or from voluntary agencies for example? There are potential
risks in medicalising all preventive activities through adopting
a clinical model of commissioning.
Public involvement
2.19 Policy and commissioning guidance has
emphasised public accountability through patient and public involvement
throughout the commissioning cycle. While, in practice, engagement
has often fallen short of an influential role in decision-making
our study showed that engagement of patients and of the public
in practice-based commissioning was minimal in the majority of
our case study sites. Many PBC interviewees had not heard of LINks,
and a few were sceptical about the benefits of public involvement
in decision-making.
Implications of the NHS white paper
2.20 What role in GP commissioning consortia
is anticipated for Local Involvement Networks (now re-badged as
Healthwatch)? How will public accountability be achieved? Will
GP consortia meet in public and will papers be made available?
Effect of economic downturn on preventive services
2.21 Our study showed that growth money
had been the main source of funds for investing in health promotion.
Few interviewees were optimistic that preventive services would
be protected in a period of economic downturn and much would depend
on how acute sector demand was managed.
Implications of the NHS white paper
2.22 Proposed arrangements arguably reinforce
the emphasis on demand management and there is a danger that preventive
services, essential for the long term sustainability of the NHS,
will be further neglected without even a framework within which
to monitor any changes.
Prioritising
2.23 Priority-setting should consider programme
goals across an entire patient pathway, including the protection
of good health; disinvestment strategies; and how to move from
reactive to proactive commissioning. This is key to commissioning
for health and well being, which demands a proactive approach
and investment over the longer term. WCC had promoted a public
health-led preventive approach to priority-setting.
2.24 This leads back to the central question
of how GP consortia populations are now to be defined.
Key Points from Partnership Working and the Implications
for Governance: issues affecting public health partnerships
2.25 The focus of the partnership study
was on the extent to which public health partnerships contributed
to improved health outcomes. Nine local areas embracing PCTs and
matching local authorities were chosen across England to reflect
different levels of partnership—strong, moderate, weak.
Although it was not possible to make any strong causal link between
the strength of partnership working and outcomes, factors contributing
to, or hindering, effective partnerships were identified. The
findings of relevance to the Health Committee's inquiry are briefly
reported here.
"Redisorganisation" and the effect on
partnerships
2.26 As the systematic literature review
on partnerships, conducted as part of the larger study of public
health partnerships, concluded, successive reorganisations of
the NHS have had adverse consequences for the effective functioning
and sustainability of partnerships. As well as causing uncertainty
for the various actors involved, repeated restructuring has required
partnerships to be reconfigured and new policy networks to be
formed, all of which has demanded additional effort and resources
to be devoted to the task. In addition, many research studies
have found that the requirement of some partnerships to operate
with partners who had different geographical and political boundaries
caused problems. For instance, different local authority and local
NHS boundaries posed particular problems for delivering some joint
services to users.
2.27 With the NHS white paper intent upon
abolishing Strategic Health Authorities (SHAs) and PCTs, already
in "meltdown" according to the NHS CEO and other commentators,
and establish in their place GP consortia and a new national public
health service, including the shift of the public health function
locally from PCTs to local authorities, partnerships as we know
them are likely to disappear. Of itself this need not be a disaster
since partnerships have had a patchy record in terms of their
impact and effectiveness. But the new NHS landscape being formed
will pose additional challenges for which we believe a new approach
may be required.
2.28 Our research demonstrates the importance
of avoiding the implication that collaboration entails neat and
tidy organisational structures and processes or is dependent upon
formal coordination machinery. Our research also shows that the
real value of joining-up mechanisms lies in their ability to foster
new kinds of conversations and relationships between key players,
including GPs. But these relationships cannot be over-engineered—effective
problem-solving, as the Institute for Government has also argued,
may come from a little chaos at the margin.
2.29 Assuming they go ahead as intended,
although there is no indication yet of their total number, GP
consortia boundaries will differ from local authority ones—existing
PCT areas in most cases mirror council ones—which could
hamper partnership working and will certainly make it more complicated.
This reflects a conundrum in NHS commissioning that has never
been satisfactorily resolved and probably cannot be. Either commissioning
bodies remain small and close to their communities (as GP consortia
are intended to do—hence the initial figure mentioned of
around 500), or they become large so they can commission effectively
across larger populations (as GP consortia are likely to become
although whether they will end up similar in size to PCTs remains
uncertain at this stage). Small commissioning bodies risk being
too small to be effective, may incur high transaction costs, and
do not share common boundaries with those with whom they need
to do business. Larger commissioning bodies may be able to share
common boundaries with other agencies, and keep transaction costs
down but risk being too remote from local communities. There is
no perfect answer, although there are likely to be far fewer than
the 500 or so GP consortia initially proposed. If GPs are to be
at the centre of commissioning, they will resist having to form
large organisations that remove them from their local patch and
suck them into high-level strategic issues that hold little interest
for most. In addition, successful JSNAs were those in which partnerships,
especially with the voluntary sector, had been established and
good sharing protocols had been embedded. Under the current changes
there is a danger that such partnerships and sharing arrangements
may be lost.
2.30 A second key fault line running through
the NHS reform proposals centres on the balance between competition
and collaboration. The government is keen to promote choice and
competition in the belief that diversity of service provision
will improve quality and deliver services that are responsive
to users' preferences. The evidence base for such a conclusion
is lacking. Indeed, greater competition in settings which require
a whole systems, joined up approach is likely to lead to fragmentation,
higher transaction costs, and more costly services. On the other
hand, if the emphasis is all on collaboration and working in partnership,
advocates of choice and competition fear that cosy and collusive
relationships will form that are not conducive to efficient or
responsive services. The answer here lies in effective leadership
and management rather than an assumption, not based on robust
evidence, that only competition can provide the necessary stimulus.
Implications of the NHS white paper
2.31 The partnership arrangements under
the NHS white paper proposals are not yet certain. Health and
wellbeing boards (HWBs) have been advocated but details of how
they would be established and operate are scant. Despite the suggestion
in the white paper that partnership arrangements will be left
to local discretion, the government seems keen to institute HWBs
as statutory bodies.
GPs and Partnership Working: messages from the
research
2.32 The main partners seen as crucial in
tackling public health issues by DsPH and other public health
specialists were the Local Authority and the PCT, the voluntary
and community sector, the police, various hospital trusts (eg
acute, foundation, mental health) and the business sector. In
contrast, user and carer groups and GPs were infrequently cited.
When asked which agencies or sectors were not involved in their
public health partnership but which they felt should be, the most
commonly cited were the business sector and GPs. It was believed
having GPs involved in their role of being able to spread public
health messages was important but it was felt by some respondents
that GPs were generally disengaged from public health partnerships.
2.33 It was believed GPs needed more representation
on public health partnerships as they could contribute to the
public health agenda in a number of ways, such as GPs acting as
"local champions" and disseminating public health messages
and generally being more involved in promoting public health.
2.34 Generally, service users believed that
services needed to be more joined up and available through their
local GP. GPs, for example, were not acting as a gateway to refer
users to services that were available in their particular locality.
Users were frustrated by the fact that a range of services could
be available in their community of which they had no knowledge.
They were obliged to make requests to agency providers to discover
such information. This, of course, reflects the lack of involvement
by GPs in partnership working which will become crucial under
the new arrangements.
Implications of the NHS white paper
2.35 If putting GPs in charge of commissioning
is problematic for various reasons, among them being the reluctance
of many GPs to engage in the activity at all and the lack of know-how
among them, then it poses a particular challenge to the reform
proposals which put GPs at their centre. A lesson from complex
adaptive systems thinking, and echoed in our research, is that
much of the power for creativity and innovation and working jointly
lies within the relationships among the parts of the complex system.
Creating supporting patterns for change is more important than
devoting effort to structures and processes. In some respects
this approach accords well with the Secretary of State's desired
strategy but its translation into policy and then practice runs
the risk that the traditional approach to change, focusing on
structure, will once again triumph over the cultural change that
is actually needed.
3. CONCLUSION
3.1 The Secretary of State for Health sets
great store by ensuring that policy is at least evidence informed
if not evidence based. If so, then the evidence we have presented
in this memorandum based on two recent major studies demonstrates
that there are high risks arising from the white paper proposals
on commissioning. It is hard to see how these can be managed successfully
if the current pace of change is maintained and at a time of significant
financial retrenchment from which the NHS is not immune. But unless
they are then the conditions for a "perfect storm" may
occur and we all be the losers.
REFERENCESMarks L,
Cave S, Hunter DJ, Mason J, Peckham S, Wallace A, Mason A, Weatherly
H, Melvin K. (2010) Public health governance and primary care
delivery: a triangulated study. Project 08/17176/208. Southampton:
NIHR SDO.
Hunter DJ, Perkins N, Bambra C, Marks L, Hopkins
T and Blackman T (2010) Partnership Working and the Implications
for Governance: issues affecting public health partnerships.
Project 08/1716/204. Southampton: NIHR SDO.
December 2010
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