Leaders speak their minds on commissioning

In a new report, Provider Voices: where next for commissioning? NHS Providers has published interviews with leaders from a range of trusts as well as from local government, local commissioning and the voluntary sector. Below are short summaries of contributions shared by NHS Providers with HSJ  - four from providers and one from local government:

David Evans, chief executive, Northumbria Healthcare Foundation Trust

My honest opinion is that the purchaser-provider split has outlived its usefulness. The NHS environment has changed hugely from the time when commissioning seemed like a good idea.

Now money is tight, the question must be whether money spent on commissioning wouldn’t be better used delivering services.

Moving to something like accountable care organisations must be worth a try.

We have aligned ourselves with the approach of the Ribera Salud Grupo in Valencia. We like their concept of a truly integrated service out of hospital, run by a joined-up delivery system.

STPs seem like a broad-brush effort to get people to sit up and think and be in the same room working together – which some organisations have never done

Since September 2013, we have managed the adult social care contract for Northumberland Clinical Commissioning Group so we are a step or two ahead of the integration game, and of letting the financial systems support it.

STPs seem like a broad-brush effort to get people to sit up and think and be in the same room working together – which some organisations have never done. The idea that they can deliver quickly may need revisiting – our clinical change in Northumbria took years and years.

CCGs are in a very hard position. Some are doing great, declaring big surpluses, but then you look at their providers in deficit, and you think “with one pot of money – is that success?”

Anthony Marsh, chief executive, West Midlands Ambulance Service Foundation Trust

Our two biggest challenges are money and increased emergency activity. Ambulance trusts like ours, covering multiple CCGs, see what commissioning looks like when it is done well (and when it is not done well).

We know what outstanding excellence for patients looks like. If we as a system can reduce variation to get all organisations up to that level, we can provide even better care with the least spend on bureaucracy, and so the least corporate cost and overhead.

We have a great opportunity for the sustainability and transformation process to be enormously helpful, but STPs will only achieve if they remove lots of other bureaucracy.

After 25 years of various reinventions of commissioning, there seems to be a real issue about the scale of NHS commissioning units

The development of ‘devo’ deals and new care models suggest that we will continue to have considerable diversity in how commissioning is delivered across the country. That need be no problem, if there is an absolutely clear direction of travel with the Five-Year Forward View and what people are meant to be doing.

After 25 years of various reinventions of commissioning, there seems to be a real issue about the scale of NHS commissioning units: both in terms of their size, and the cost of commissioning versus the value added by the commissioning process.

We need to think about whether, given the substantial cost of commissioning, it really provides value for this investment.

Nick Moberly, chief executive, King’s College Hospital Foundation Trust

We have an exceptionally demanding set of expectations in the NHS in terms of the quality of services to be offered; the level of access people can expect to be commissioned; with inadequate funding available to pay for them.

Implicit in that challenge is the requirement for commissioners and providers to drive a transformation and change agenda, which is seriously tough.

The corresponding opportunities are to seize the moment, to make the most of the funding available and, working with providers, to rethink how services may be delivered.

A more consolidated model might make sense as part of a move to novel ways of commissioning

The underlying STP process recognises that individual organisations on their own can’t make the headway and progress that genuinely transforming care requires, so the only way to do improvement of quality and efficiency at scale and pace is for commissioners and providers in broad geographic networks to work on problems together in a collaborative way.

I certainly see blurring of the traditional roles of commissioner and provider ahead.

Increasingly, as STPs take hold and sub-regional planning takes place, we have to ask whether CCGs are operating across too small a geography. And in principle, a more consolidated model might make sense as part of a move to novel ways of commissioning, based on integrated, population-based analysis and outcomes-based capitated budgets.

Carolyn Regan, chief executive, West London Mental Health Trust

I worked on the mental health strategy in north-west London as a commissioner, and I have come back as a provider to implement the strategy.

The transformation agenda is huge: the most impact recently has been from our work around the single point of access. All referrals now come through phone or email, both of which are available round the clock.

We are developing a host of other things including primary care plus workers with GPs and an extended CAMHS service.

This is a good time for new models of care in mental health and trying new things. It is also about partnership with other organisations and trusts.

We know that many CCGs are very small for the job they are tasked to do

The challenges facing a commissioner are no different than for a provider: quality and finances. Within that, there is partnership working and innovation: an opportunity to do something radically different and transformative.

The STP process is clearly meant to drive more alignment between commissioners and providers over a larger footprint. Our track record in north west London is very good, so we are building on a solid foundation.

We know that many CCGs are very small for the job they are tasked to do. Their challenge is to keep the unique local perspective, and also achieve economies of scale. Bigger commissioners have a better chance.

Councillor Izzi Seccombe, chair of the Local Government Association Community Wellbeing Board

Local government has been actively commissioning services for decades and sees commissioning as a continuous ongoing process. This starts with an assessment of needs, followed by an identification of priorities, market and demand management, contract development and procurement. The NHS sometimes focuses narrowly on procurement, and would benefit from adopting a whole-cycle approach.

Local government increasingly focuses commissioning on achieving improved health and wellbeing outcomes rather than purchasing activity. This approach is person-centred and doesn’t just treat individual health conditions. Its focus is on what matters to the individual and what they want to get out of their life.

Successful commissioning needs an equal conversation between commissioners and providers

Once this is agreed, a local authority commissions services to support the person to achieve their goals. The NHS still often commissions for a certain number of units of treatment, rather than using a person-centred approach.

Commissioning for outcomes along complex pathways poses a particular challenge for the NHS, as the vast majority of money passes through tariffs based on activity and not outcomes.

Successful commissioning needs an equal conversation between commissioners and providers. In the NHS, that relationship needs rebalancing.

There is real potential for STPs to reshape services for the benefit of their communities, but they need to be genuine partnerships between health, local government and the community and voluntary sector.

Read the new report here.