World class commissioning: NHS sets out to lead the world

Put simply, commissioning is designed to 'add life to years and years to life'. Using world class commissioning, we expect primary care trusts, with their partners, to improve the quality and personalisation of healthcare (adding life to years) while improving life expectancy and reducing inequalities (adding years to life).

The Commonwealth Fund paper Mirror, Mirror on the Wall: an international update on the comparative performance of American healthcare, claimed that the UK had one of the most progressive and high-performing health systems in the world while noting areas for improvement, including access and personalisation.

The report indirectly pointed to one of the great latent strengths of the NHS - its efficient system for resource collection and distribution, which ensures that its health insurance model universally covers the population. These strong foundations present an excellent opportunity for PCTs and practice-based commissioners to use their collective purchasing power to get better population health, clinical outcomes and patient care. Couple this with our rich yet under-exploited clinical data streams and we have good pre-conditions for successful commissioning.

Improvements must not be patchy: all commissioners will need to set clear goals for outcomes. Their competencies and plans for achieving these objectives will be subject to professional scrutiny through a new compliance and assurance framework. This system will be designed to liberate the best while ensuring that the modest improve.

Ironically, 'world class' commissioning is best when it is local. Its importance lies in the fact that demography, lifestyles and disease are changing so we need a renewed focus on long-term conditions, lifestyle consumption and an ageing population. Annual targets have a place but they cannot respond to the changing nature of disease in a strategic and systematic fashion. These challenges must be tackled locally.

Similarly, significant variations in health inequalities across England have to be tackled locally. PCTs need to form enduring alliances to do this with a variety of stakeholders, partners and providers.

World class commissioning will be the delivery vehicle for world class clinical services and a world class NHS. In his interim report, junior health minister Lord Darzi talked about an NHS that is fair, personalised, effective and safe, and set out immediate actions, for example a strategy for reducing inequalities, and more flexible GP opening hours (which in itself will require a step change in commissioning). World class commissioners and their partners will be the key enablers of such objectives.

Stuffing pockets

Pockets of very good commissioning already exist. For example, Heywood, Middleton and Rochdale PCT, Sport England and the Big Lottery Fund have joined forces to regenerate local sports facilities. The PCT has also employed dedicated community workers to encourage healthy lifestyles and improve public health. In Bournemouth and Poole, the PCT has, with its practice-based commissioners, set up a community-based palliative care service that is improving end-of life-care.

But pockets are not good enough, and world class commissioning means all commissioning organisations delivering the best, and being the envy of all health systems across the world.

In order to support the vision for world class commissioning, it is important to understand the key organisational competencies that PCTs will need to demonstrate, which are set out below:

Locally lead the NHS PCTs will be seen as visible leaders of their local NHS, with a high profile in the community. They will represent the local NHS in dealings with community partners and act as advocates for the people in their communities.

Work collaboratively with partners A key skill for world class commissioners. PCTs will develop a shared ambition with local partners through open and honest dialogue. These relationships will be built up over time, reflecting the commitment of partner organisations to innovative solutions for the whole community.

Partner with patients and communities By developing long-standing and inclusive relationships with their public, PCTs and practice-based commissioners will ensure they have a clear understanding of the needs and priorities of the population they serve.

Partner with clinicians PCTs will ensure that services commissioned build on the current evidence base by involving clinicians in strategy and service design. PCT professional executive committees will provide a focus for clinical leadership in the trust, and especially practice-based commissioning.

Manage knowledge and assess needs World class PCTs will base their decisions on sound knowledge and evidence. They will anticipate and address the needs of the whole population, including people with long-term conditions. A joint strategic needs assessment carried out by PCTs and local authorities will provide a rich picture of current and future needs. This will result in better actuarial analysis, population segmentation and risk stratification.

Identify investment requirements and opportunities World class commissioners will bring together feedback from their population with knowledge they have gathered about current and future needs to agree the outcomes that they want to achieve. This will provide a clear strategic vision of the future, delivering better health and well-being for all, and a reduction in health inequalities.

Influence provision to meet demand and secure outcomes In order to deliver their local vision, world class commissioners will shape and reform the market to deliver a choice of high-quality services. By developing close working relationships with current and potential providers, commissioners will ensure that the market delivers choice, innovation and improvement for its population.

Drive continuous innovation and improvement World class commissioners will seek innovation, knowledge and best practice, applying this locally to improve commissioned services.

Deploy procurement skills to ensure providers have appropriate contracts Excellent procurement and contracting processes will ensure agreements between commissioners and providers are set out clearly and accurately. PCTs will have timely and continuous control over contracts, ensuring that they deliver good value.

Manage finances PCTs will be able to minimise the financial risks involved in commissioning and take a proactive approach to financial management. They will ensure that their commissioning strategy is affordable. An emphasis on health investment as well as spend is crucial in this respect.

Grassroots feedback

For the vision of world class commissioning to succeed, it must be developed, articulated and owned by the local NHS.

Recently the Department of Health, with the NHS Institute for Innovation and Improvement and the NHS Confederation, held an event at Warwick University that brought together 75 leading thinkers from across the NHS, local authorities and other partners. They discussed the vision and competencies for world class commissioning as well as the assurance system to hold commissioners to account.

Following a process of refinement incorporating such feedback, the vision and competencies for world-class commissioning will be formally launched later this year.

The assurance system will help commissioners towards world class performance. The DoH is working closely with PCTs, strategic health authorities and regulators to design this system. It is likely to include an assessment of governance, including the PCT's strategic plan, and measurement of the competencies and health and patient-reported outcomes.

The detail of the system is still being developed, but the intention is to develop a prototype system by Christmas, which will be tested early in the New Year. There will be one system of assurance, managed by SHAs, which will be based on a number of design principles. It will be transparent with clearly defined sanctions, incentives and freedoms. It will be based on a dialogue, and will be developmental, so that as commissioners demonstrate greater competence, they earn greater autonomy. Where possible it will use existing data, such as that collected for the health and social care accountability framework.

The vision, competencies and assurance system will be complemented by a framework to support and develop commissioners. This will offer resources for sharing, for example sharing best practice, or sharing services such as the West Midlands Commissioning Business Support Agency; for building internal capability, such as the NHS Alliance/Humana commissioning academy; and for buying in external expertise, for example the framework for procuring external support for commissioners, launched just a few weeks ago.

It is an exciting time for commissioners. World class commissioning will be an entirely new form of commissioning and PCTs, practices and their partners will need to rise to the challenge.

What it will deliver

World class commissioning is not an end in itself, so in order to prove successful, commissioners will need to demonstrate these outcomes:

Better health and well-being for all

• People stay healthier for longer, improving the quality of their lives.

• People live longer and health inequalities are dramatically reduced.

Better care for all

• Services are of the best clinical quality, which is evidence based.

• People exercise choice and control over the services that they access so they become more personalised.

Better value for all

• Investment decisions are made in an informed and considered way, ensuring that improvements are delivered within resources available.

• As health investors, PCTs work across organisational boundaries to maximise investment in care.

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