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The NHS Commissioning Board: biggest of the big spenders

The NHS Commissioning Board’s greatest influence on quality will be through how it splashes its cash

“Patchy” and “variable” have always been useful words to describe services and progress in the NHS. I have often used them myself, safe in the knowledge that they would be true, even without detailed survey evidence. Consistency has never been an NHS strength, except recently when meeting “must do” targets and standards. How could it be otherwise with 152 commissioning organisations and many more providers?

Want to complain about your GP? Email Sir David

But the NHS Commissioning Board may be about to change that. Commissioning consortia may get the headlines, and the board has so far been seen through the consortia lens - how it will approve consortia, ensure they manage their risks, and so on. But the biggest influence the board could have on quality of care is through its own commissioning, which so far has largely escaped scrutiny.

The board will be big, very big, even without responsibility for maternity services. In 2009-10 the NHS spent £11.1bn on primary care, excluding the primary care drugs bill. Then there is an estimated £5bn or so spent on national and “regional” “specialised services”. This gives the board £16.1bn - one-fifth of all primary care trust spending, making it by far the biggest kid on the block.

This is money for spending, not for allocating to subsidiary organisations, which has been the traditional job of regional or national bodies. This is healthcare commissioning on a scale never seen before in this country. For comparison in the private healthcare insurance stakes, BUPA’s UK and North American division’s turnover was “only” £2.1bn.

It will also mean a centralist approach to care that is very local. Need to be allocated to a GP practice? Write to NHS chief executive Sir David Nicholson. Want to complain about your GP? Email Sir David. Want to campaign about a local pharmacy? Contact Sir David. Now, I am sure he would much prefer not to be contacted in this way and that regional branches of the board will handle such matters. But, even if they do, responsibility will rest absolutely with the centre.

Sleek and efficient

However, this is an opportunity for stronger, more consistent, commissioning. There will be no need to reinvent approaches. Provision and analysis of information should be stronger. The back office should be sleek and efficient. This is, after all, the ultimate in shared services.

Specialised services show the possibilities. The current PCT-led specialised commissioning groups do not all commission the same services. They also have not reached the same stage of development. Nor do they have the same expertise.

The headline figures also suggest substantially different resourcing and approaches. For example, according to the National Specialised Services’ report, the South West group spent £147m on specialised services for five million people in 2008-09. The Yorkshire and the Humber group spent £305m on a similar size population. The North West group spent £922m on seven million people.

These figures undoubtedly hide many differences. But they suggest to me the estimated £5bn spent on specialised services could be too low. The total commissioning board spend could approach £20bn.

Increasing the board’s coverage of specialised services is one way of limiting the financial risks for consortia. Spend on these services has been rising rapidly. They are the services likely to be used to treat the most expensive patients, and they are also provided by the most powerful trusts, where no one consortium will be a dominant purchaser.

Such an approach would mean commissioning consortia taking responsibility for purchasing day-to-day district general hospital and community services, leaving the more specialist end of care to the Commissioning Board. This could be a good outcome as these are precisely the areas with which GPs are most familiar and can have most impact in their own clinical practice. And the board would have the major say on service change through its own actions as a commissioner.

The board will have to deal with some of the more difficult issues at both ends of the commissioning spectrum. London is the clearest example of where the board could drive reconfiguration through its specialised services commissioning responsibilities but will also have to deal with the problems of providing inner-city primary care.

There are possible downsides, notably whether a central organisation will be able to tailor its contracting to local circumstances. GP practices, pharmacy and dentistry are all local services that have benefited from localised contracting through, for example, personal medical services contracts which now, sadly, look in danger of disappearing. How it divides money between itself and consortia will also be a tricky issue.

It is also a final make or break test for commissioning and its ability to drive improvements in quality and efficiency. The board will have financial clout, the pick of commissioning expertise, the ability to apply good practice from around the country and all the other levers anyone could want. There can be no excuses.

Readers' comments (2)

  • As long as they remember to include exit/termination clauses in their contracts!

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  • More centralised commissioning of specialist care ? Makes sense.
    But for primary care it's an act of unmitigated idiocy and one of the stupidest ideas the White paper contains. Primary care is by its very essence a local issue, needing loccal voices and local solutions.
    Quite tellingly, at the Pathfinder Conference in London last week, David Nicholson was asked a fairly straightforward question; if we're really seruious about shifting resources and services locally away from hospital-based care, then how excatly do we achieve that in practical, basic decision-making and investment steps ? Nicholson ducked the question. Indeed, the questuion has been consistently ducked. All we've had is endless rehearsals (and Sir david did the same last week) about the need to avoid conflicts of interst, and the necessity of appropriate organisational behaviours. No solid, practical, 'how do we get from A to B ? ' answers.

    The GPs on my patch are asking it too. Repeatedly.And I can't give them an answer. If anyone can point me in the direction of anything that gives some answers, I'm all ears and eyes.

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