We're no closer to knowing if 'commissioning' is worthwhile or not

In 1971, a man calling himself Dan Cooper hijacked a Boeing 727 flying from Portland to Seattle in the US. After exchanging 36 hostages for $200,000 he parachuted out of the plane and was never seen again.

Numerous investigations have sought to find evidence of what happened next without success; the whereabouts of Cooper and his cash filled suitcase remains a mystery.

In the NHS, we have our own version of Dan Cooper – several decades of searching and speculation have brought us no closer to knowing if the introduction of “commissioning” has been worthwhile or not.

‘We are no closer to knowing if ‘commissioning’ is worthwhile or not’

Now with the advent of “outcomes based commissioning”, are we edging towards a better understanding of the value commissioning can bring, or closer to calling off the search and abandoning the concept altogether?

We start from a place of scepticism: major studies on the evidence of commissioning in the NHS, by Julian Le Grand (1998), Judith Smith (2004, and again in 2011 with Natasha Curry), have a similar message, summed up by Smith and Curry: “When weighed against the transaction costs of running a commissioning system, the verdict would seem to be weak or at best equivocal.”

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Evidence

Amid all the change of the last Parliament, it is worth remembering clinical commissioning groups are barely 30-months-old – we know GP engagement is higher than under practice based commissioning, but it is too early to know the full impact.

Set against this uncertainty are the challenges that commissioners face:

• an unprecedented financial challenge;
• that of maintaining and, if possible, improving quality of care; and
• supporting providers to transform how they deliver care as prescribed by the Five Year Forward View.

It is no surprise that commissioners are increasingly looking at new ways to go about their business.

Enter “outcomes based commissioning”. This term (best thought of as a brand name more than a description) is an approach based on the use of five components: outcomes, population, metrics and learning, payments and incentives, and coordinated delivery.

Its development has been closely intertwined with the rise of new contracting models, such as “prime provider”.

The logic is that providers are incentivised to collaborate to produce integrated services capable of improving outcomes and reducing waste.

It is generating a lot of excitement; last year HSJ’s clinical commissioning group barometer showed that three-quarters of the 109 CCG leaders who participated thought it was likely or very likely they would re-contract a significant amount of spend under an “integrated” contract covering a defined population.

‘The evidence base behind it reflects the novelty of the approach’

The evidence base behind it reflects the novelty of the approach. The first NHS schemes only started in 2011, and while international examples are cited (most often the “Alzira” model in Valencia run by the private health care company Ribera Salud) these arise from atypical contexts, and are accompanied by a lack of robust independent studies.

From our work at the Health Foundation (culminating in our report Need to Nurture: Outcomes-based Commissioning in the NHS) it is clear that a number of areas developing outcomes based commissioning schemes are seeing it as a means to move away from commissioning.

Big bang

Northumberland, Somerset and South Nottinghamshire CCGs have all published proposals for whole population contracts (potentially with values of £700-£900m per year, roughly the annual GDP of the Seychelles).

What happens to the residual role of the CCG in such schemes is uncertain – if it exists at all. One CCG accountable officer we spoke to had banned the word “commissioning” from their organisation as an “outdated concept”.

However, this scale of approach is still the exception rather than the rule. Most other areas are looking to use outcomes based commissioning either for a clinical area (most typically musculoskeletal care) or a single population group (often older people).

Interestingly, the big bang approach also goes against the path of accountable care organisations (ACOs) are taking in the United States; experts such as Mark McClellan at the Brookings Institution point to some of the most advanced ACOs being those that have started small and progressed incrementally.

Implications

Instead of being the death of commissioning, a much more likely implication is that commissioning needs to change in two keys ways.

First, to become more strategic, allowing providers to innovate with the more “tactical” commissioning functions such as service design. Even under a Somerset style approach, strategic functions, such as holding providers to account, need to be undertaken by someone – even if it is not CCGs.

‘Commissioning needs to change in two keys ways’

And second, to become more shared across health and care services, and broader determinants of health, to allow for a holistic focus on promoting individuals’ wellbeing.

Both implications point to commissioning organisations being smaller, increasingly joint with local government, and likely to cover larger areas.

They also need to be more expert: the vast majority of the CCGs we spoke to had found using an outcomes based commissioning approach was significantly harder and took significantly longer than they had expected (even with many having relied heavily on external consultancies to support them).

Debate

Too often our conversation as to the future of commissioning turns quickly to a binary decision of whether to keep it or scrap it – rather than the more nuanced debate as to how could it be made to work.

Action locally and nationally could help: locally with far-greater peer-to-peer learning between areas experimenting with this approach, nationally with a combination of NHS England and Health Education England looking to do more to train and develop commissioning talent.

‘A binary decision of whether to keep it or scrap it’

If we expect our search for commissioning to see a positive impact, we need to spend more time supporting its success in the first place.

The failure of 40 years trying to find Dan Cooper is likely to reflect, at least in part, a lack of expertise on behalf of the FBI in their search.

In that case, lessons were learnt, expertise improved. In 1972, 15 others tried to emulate Cooper – 15 were caught.

Richard Taunt is director of policy for the Health Foundation, and Clare Allcock is senior policy fellow for the Health Foundation and head of primary care and community development for Horsham and Mid Sussex, and Crawley CCGs