A development programme for clinicians taking on commissioning responsibility is equipping participants with a vital set of skills ahead of the changing NHS landscape, says NHS Derbyshire County’s executive director clinical quality and nursing Maggie Boyd.

Health professionals at all levels are to have a greater say in the way NHS services are commissioned and distributed in their neighbourhoods. Practice based commissioning and world class commissioning began the process of engaging medics in helping to shape the services, but often there is no preparation, so much of the learning is done on the job.

Public spending cuts, increased public expectations around quality and service, disinvestment and the cycle of the commissioning process – from decision making through to safe delivery of care – are just some of the reasons GPs, senior nurses and other healthcare managers should be given the right training that will help them manage the complex health and social programmes of the future.

It is very challenging to leave clinical practice and make the transition to a commissioning role. A stakeholder event identified why a learning programme is necessary (see box, below). In response, NHS Derbyshire County has started to roll out an innovative programme with Derby University for these purposes.

There is an important leadership role in encouraging and attracting clinicians to be engaged in the commissioning process, developing a programme that equips clinicians to be more confident with quality improvement and cost containment.

A greater say

The development programme, launched in September last year, is one of the first of its kind.

Katie Cuthbert, Derby University principal tutor within the faculty of education, health and sciences, was involved in the early design.

Dr Cuthbert says: “The white paper recommends senior clinicians take charge of budgets and commissioning services in their neighbourhoods. Such health professionals will find themselves with a greater say in their community’s health – not just that of the individuals they treat. This development programme will empower them with the proposed commissioning changes ahead.”

To date, 25 delegates from a range of backgrounds – GPs, psychiatrists, pharmacists, nurses and health informatics – have taken part. The programme consists of five classroom-based days with contributions from local and national leaders and experts, which have included PricewaterhouseCoopers, PA Consulting, non-executive directors, policy makers, local authority chief executives, primary care trust senior staff and the NHS Institute for Innovation and Improvement.

The programme has been supported by Derbyshire Healthcare Foundation Trust non-executive director Maura Teager as project manager for the trust, with contributions from the NHS Institute, Health Foundation, Department of Health and Queen’s Nursing Institute in the early design. The programme is multidisciplinary, networking local clinicians across primary and secondary care.

During the development phase we employed a co-production ethos, recognising the expertise and experience among the participants. The aim for the programme was to work in partnership to meet the development needs and learn together to equip the participant with the necessary skills in the following:

  • commissioning cycle and processes;
  • financial and planning health services;
  • governance and assurance;
  • leadership skills through change;
  • business processes, contracting, finance and procurement;
  • complex decision making;
  • quality improvement.

Academically validated by Derby University to carry 30 postgraduate credits, participants learn in a number of ways. Working in four action learning sets, participants use appreciative enquiry techniques and reflective practice methods.

The appreciative enquiry philosophy is a form of problem-solving through value-based discussions with the ultimate aim of bringing clarity to the future roles and functions of commissioning.

There is a strong emphasis on consolidating the participants’ clinical identity – where many commissioning programmes merely expect the participants to “become” managers, this programme reaffirms the importance of the clinician making informed commissioning decisions.

The main lessons

  • Good governance is not an add-on
  • Complex decision making on investment and disinvestment needs processes that stand up to scrutiny
  • Quality information is needed
  • Practical based problem solving in learning sets is essential
  • Change management, working in teams, influencing and negotiating are key skills
  • Contract management is a transactional process commissioning is much bigger

Reflective practice requires the participants to complete a personal learning log that helps them track their journey through the course. During the programme participants encounter some challenges to their previous mindset – the opportunity to reflect is an important component of this transition to a clinical commissioning focus. The personal log also contributes to the final assessment.

Trigger presentations are introduced within the timetable with questions to promote discussion and capture the learning. As part of the final assessment the participants are required to act as a clinical consortium and present the cycle of commissioning on a chosen care pathway. An executive panel will then debate and challenge the processes, outcomes and learning.

In addition, participants submit a written piece identifying their personal development strategies for taking their commissioning roles forward.

The programme will be formally evaluated and inform future development work.

It is envisaged that the first cohort will provide mentorship to the second cohort and develop alumni to support clinical leaders. This will support a local learning community, strengthening local networks across primary, secondary and social care. The next cohorts begin in autumn this year.

Starting a debate

Giving time and space to individuals during major changes in policy is time well spent, allowing shared learning as policies have been issued.

The programme has allowed a debate about what the primary care trust was not so good at despite good effort and what needs to be addressed in the transition process. For example good working relationships with clinicians were variable; target culture and governance were considered as bureaucracy; focus on outcomes was patchy. This has allowed thinking and direction on the shape and development of the consortia.

One session focused on the findings from the Mid Staffs scandal. It was an acute reminder that focus on money and targets at the cost of patient care and investment in staff was not acceptable.

As we develop commissioning models the responsibility and accountability for decision making should stay at the heart of the professional’s code.

Why have a learning programme to prepare clinical commissioners?

  • The shift from individual to population needs assessment leads to difficult and challenging decisions on healthcare
  • To address the professional conflict with decision making – consider all patients’ needs, care or treatment
  • Learn the art of influencing and negotiating – little experience in corporate roles as clinician
  • Learning from other organisations
  • Demystifying commissioning
  • To account for policy and politics within organisations, professional across strategic health authority and nationally
  • To understand power bases and how the NHS works
  • Develop skills in service specifications, business plans, contracts, quality schedules
  • Equip clinicians to make a bigger difference
  • To make commissioners confident in using relevant data
  • Develop project management skills and programme budgeting
  • Develop knowledge base to be confident within the complex commissioning context
  • Develop interpersonal skills to manage relationships and conflict