Those of us working with the changes taking place in the NHS will recognise that much of the radicalism of ex-health secretary Andrew Lansley’s original reforms have run into the sand.
Clinical commissioning groups will have more accountable officers from past primary care trusts than GPs, the foundation trust pipeline will not be turned into a flood but will remain a dribble and most of the new integrated providers could well be seen off by the old NHS institutions of the past.
One part of the original radicalism that will thrive will be the mandate from the health secretary to the NHS Commissioning Board to drive the NHS towards better outcomes.
For example, the board will be expected to spend the public’s £85bn on improving the number of years that people with long-term conditions have a good quality of life.
Spending public money improving health outcomes rather than inputs is unequivocally a good thing and I would hope the whole work of the board would be to enthusiastically carry this out.
I think the mandate will get a good response from most CCGs. Most of the GPs I work with want to commission for outcomes, not inputs. They recognise that their patients want recovery and not to be passed around a system of different and complex inputs.
The only downside to this is practical. While the board will be expected to drive towards outcomes, nearly all of the tools that it has to hand are contracts about inputs.
If I was on the board this would worry me. I will be signing up to a big public national contract to deliver outcomes but that would be undermined by all the tools that I am trying to get the CCGs to use, which are about inputs.
None of us would be surprised if over the next few months the new commissioning support units are telling “their” CCGs that it is essential the CCG works towards outcomes but have to use contracts with their local providers that are just about inputs.
Some of the commissioning board’s staff could well spend much of the next six months undermining its ability to hit the outcomes of the mandate that the board itself has signed up to. But there is help at hand. The new GP commissioners and others in the system are looking at alternatives that could commission for outcomes.
CCGs are looking at the development of alliance contracts where the commissioner has one contract with an alliance of parties who deliver a service or project. As these differ from traditional contracts, where there will be separate contracts with each party, usually with different objectives, it is possible to expect that alliance to move towards patient outcomes.
This creates integration and collaboration without the need for new organisational forms. Parties to the contract come together to agree the objectives, align their own organisational ones with the overall ones, and agree a risk share. Having one overall performance framework means that all parties have a stake in the success of others.
At the moment Lambeth is working through how it can use an alliance contract in mental health services to get all providers working together to transform services from crisis based to enablement.
In another part of the NHS, GPs have helped to develop a capitation outcome-based incentivised contract (COBIC). The COBIC approach to commissioning will allow those CCGs that want to concentrate on outcomes and getting better value for the public and patients to develop a contract that will work towards outcomes.
Two contracts on substance misuse and sexual health have already been signed using COBICs in Milton Keynes and several CCGs are working to develop them for topics as diverse as continuing care, mental health and the frail elderly.
The board knows about these developments and some members recognise that it would be very useful to have even a small part of the NHS actually commissioning for outcomes.
Over the next six months we will discover if the board as a whole can allow and encourage such an innovative approach to contract development.
Paul Corrigan is a management consultant and executive coach, www.pauldcorrigan.com.