More care in community settings is a must for a sustainable NHS as well as a healthier environment, says Jennifer Taylor

Commissioning can promote sustainability by looking beyond traditional healthcare, says national director for primary care in the commissioning and system management directorate David Colin-Thomé.

We need to challenge much more brutally the amount of money we spend on interventions of low effectiveness

That approach lends itself well to the quality, innovation, productivity and prevention (QIPP) drive because commissioners need to challenge how money is spent.

In practice based commissioning, for example, clinicians can challenge clinical practice to cut duplication, but also to focus spending “on things which are not only low carbon but also more sustainable for a healthier future, which is the whole principle of sustainable development”, says Dr Colin-Thomé.

Primary care trusts also need to work with local government and focus on health and wellbeing through joint commissioning.

Close to home

To achieve healthcare that is more sustainable and also low carbon, commissioners can try to get more care closer to home, promote self care and self management for people with long term conditions and focus more on prevention.

Dr Colin-Thomé says: “We need to challenge much more brutally the amount of money we spend on interventions of low effectiveness, where there’s duplication, and where much care that’s currently done in hospital could be done in community settings or even not done at all if we empower patients. Commissioners can influence that.”

NHS Sustainable Development Unit director David Pencheon says the NHS needs to move away from commissioning processes towards commissioning pathways of care. That would incentivise providers to be more innovative in how they deliver services.

The criteria when commissioning a service would be high quality, value for money, effectiveness, and convenience for patients.

“You would find that things would be almost inevitably more sustainable in terms of the use of other resources, like people travelling,” says Dr Pencheon.

Large contracts

NHS South Birmingham spends £660m a year, which makes it a big player, but the PCT is only just beginning to realise the potential of holding large contracts.

“There’s a paradigm shift change when you stop thinking of yourself as a small provider and start thinking of yourself as the lead commissioner,” says PCT chair David Cox.

The PCT holds monthly meetings with providers and in the last couple of years has made major drives on quality. It is now putting sustainability objectives into the prequalifying questionnaire when retendering a service.

Many environmental moves in the NHS have focused on acute providers but, says Professor Cox, “if we’re the leaders of the local health economy we need to be taking the initiative as commissioners”.

The prize of the future is working in partnership across a whole health economy to make it more sustainable. That could include sharing transport, having joint approaches to waste and making purchases together.

PCTs are responsible for their local health economy when it comes to quality, but Professor Cox argues that the responsibility can extend to sustainability.

PCTs can use contracts to monitor providers’ progress on carbon saving targets in the same way they check on quality and complaints.

South Birmingham sits around the table with its main providers and runs their business plans forward financially for four years to predict the financial impact of achieving their targets. If the outlook is unviable, they look at how to make the health economy sustainable. In future they will do the same exercise for carbon reduction.

“It really is developing the potential of commissioning,” says Professor Cox. “We’re doing it financially, we’ve done it on quality and we’re going to start doing it on sustainability.”

Sustainable commissioning: a win-win situation

NHS commissioners have huge power and with that comes huge responsibility. Holding over 80 per cent of the NHS budget, they make decisions that can have immediate and long lasting consequences in the communities they serve. This means if they commission sustainably they could also shape a far more low-carbon NHS.

With this in mind the NHS Sustainable Development Unit, along with the Sustainable Development Commission, are publishing two documents about sustainable commissioning and the win-wins that can be achieved.

These win-wins include greater efficiency, better value for money, less waste, improved health benefits for patients and a closer harmonisation with the local community.

For example, commissioning a locally based health service that employs local staff can improve social networks. Commissioning a service that uses more local food for patients can improve local employment and is also more sustainable.

Key actions for commissioning sustainably are:

Top tips

  • Promote care closer to home, self care and prevention
  • Commission pathways and outcomes rather than processes
  • Use contracts to monitor providers’ progress on carbon saving targets