Amid the controversy around the government’s NHS reforms, relatively little attention has been given to the role of the NHS Commissioning Board.

The absence of a national body with a focus on commissioning has been a weakness for the NHS in the past. The board has the opportunity to significantly improve the way commissioning is delivered at a time when strong commissioning is vital. But if it fails, it could undermine the chances of clinical commissioning groups working well.

The style the board adopts will play a significant part in its likely success. There has been much talk of the need for CCGs to be different from primary care trusts. The need for the board to be different from the Department of Health and strategic health authorities is rather more pressing.

The board will be responsible for directly commissioning around £20bn of services, including primary care and specialist services. It will also initially take on responsibility for commissioning local services where CCGs do not choose or are not authorised to do so themselves.

It is impossible to know the scale of this, but a £50bn-£60bn commissioning budget initially is not unfeasible.

The board will support the CCGs to deliver effective commissioning and hold them to account. It will be important to get the balance between these two functions right. Too much central direction would limit local innovation, but too little control and direction could see unwarranted variation in performance between groups.

This is not a new problem for the NHS, but is particularly delicate at this time. Financial pressures tend to lead to command and control, which is unlikely to deliver the clinical engagement necessary to deliver productivity gains.

CCGs will need a clear performance framework and simply focusing on outcomes and money is not enough, as outcomes may take years to become clear. There should be four distinct components to the performance framework: financial performance; quality of local health services; health outcomes for their population; and strategy/governance.

The DH never satisfactorily developed such a framework for PCTs. Getting the right balance of sticks and carrots is critical.

Drowned in guidance

The framework needs to be powerful enough to incentivise clinicians to take their commissioning role seriously, but not so powerful that it risks distorting the patient/doctor relationship in clinical decision making.

The role of the board in developing the quality premium is vital. Ensuring that the board is able to effectively incentivise clinical commissioners to participate in the new system will become even more important now the deadline to take on commissioning responsibility has been removed.

It would be easy for the board to succumb to the temptation to drown CCGs in guidance on the basis that expertise will be spread too thinly, but too much guidance done badly could be perceived as being overly directive and controlling.

There are some simple steps the board could adopt to avoid some of these hazards:

  • Focus on pulling together clinical evidence and avoid duplicating effort across CCGs;
  • Ensure commissioning guidance is practical and useful. Lengthy strategy documents are often unhelpful. Focus on practical material which can be “cut and pasted” into local contracts, such as model service specifications, benchmarking tools or quality markers;
  • Be clear it is guidance, not instruction. CCGs should be free to ignore it provided they have good reasons to do so;
  • Make sure CCGs have control over what areas are prioritised for commissioning guidance because the existence of guidance can distort local priority setting.

The board will be responsible for commissioning primary care but could delegate some responsibilities to CCGs. Delivering improvements in primary care is one of the key opportunities in the NHS reforms. The absence of formal performance management responsibility could weaken the potential for CCGs to drive improvements in primary care. It will be important for CCGs to have leverage over quality and value for money in individual GP practices.

While it is important for the board to retain responsibility for payment of practices, practice development is an essential role for CCGs as their success as commissioners is directly related to the effectiveness of their member practices.

Dealing with failing practices must ultimately be a role for the board, but there need to be effective links with CCGs to maintain confidence that decisions are taken with local input and feedback from commissioners.

The establishment of the board could be seen as a significant centralisation of power in the NHS so it is important for it to have clear and transparent decision making processes to ensure effective accountability. Where the CCGs have not taken on their commissioning responsibilities, and the commissioning board steps in to commission local services, local accountability will be even more critical. The spectre of the commissioning board as the largest and most unaccountable quango in the country is not appealing.

Ultimately the single focus of the board on commissioning is a great opportunity to shift national thinking away from a focus on provider interests. However, it is easy to see how the board could be diverted from this clear focus by adding a potentially long list of other current DH functions, which have no obvious home. This mission creep should be resisted if we want the board to be a success.