The Integrator: Commissioning’s unlikely saviour

Much has already been said about the current government taking inspiration from the 2000s — but the full extent of the desire to revive the NHS structures of that era is only now becoming clear.

The NHS will be run from the Department of Health and Social Care. Payment by Results is back. Some form of regional strategic health authorities are on their way. Heck, now even commissioning is making a comeback.

Sir Jim Mackey, like many leaders of strong and successful foundation trusts through the 2000s and early 2010s, was not coy about his frustrations with the local commissioners — primary care trusts, then clinical commissioning groups — with whom his Northumbria Healthcare Foundation Trust was regularly at loggerheads. To put it mildly, he was not the biggest advocate of robust commissioning.

When the 2014 Five Year Forward View raised the possibility of virtually wiping out the purchaser/provider split, Northumbria was among the first to try to make it happen — by way of the latter eating the former. But the FYFV-inspired attempts to establish formal “NHS accountable care organisations” failed.

Instead, Simon Stevens moved on to creating integrated care systems, which proved a much more successful way of subverting the purchaser/provider split in the NHS, reinforced by a huge shift in rules and incentives towards collaboration and system working. Catalysed by covid, it brought us here.

And Sir Jim — while being careful to not explicitly criticise the decisions of his predecessors — is clearly not a fan of the result.

Lo, a new champion of commissioning is born.

Localising the cap

The NHS’s 180-degree turn back towards commissioning has been brought to life during national discussions in recent months about what to do about the elective “payment limit” cap. Planned care spending surged in 2024-25, and the cap was a national measure to keep a tight lid on it in 2025-26.

It will now be replaced by asking local commissioners to do better at keeping a lid on it themselves locally.

Sir Jim — who was given the NHSE elective brief a month after Amanda Pritchard became CEO in 2021 — said during the national deliberations: “I was a bit embarrassed myself… that the contracting rules we’ve got don’t actually support proper contracting.”

Pleading guilty to nostalgia for the late 2000s era, when NHS performance was strong and improving and deficits a rarity, he told HSJ last week: “I still think of commissioning like I used to think about it, to be honest… We’re all doing reminiscence therapy, thinking about when this thing worked…

“We’ve lost a huge amount of capacity and capability. And whilst nobody enjoyed the terrible contracting rounds that we used to have at times, we’ve over-corrected, and now it just feels like a very remote kind of spreadsheet allocation thing… We’re going to have to redevelop commissioning and contracting capabilities.”

Recalling the old days as Northumbria CEO, Sir Jim said: “I would be used to a contract that said, ‘[You will be paid] PbR, but when you get to this volume, or when you get into the last couple of months of the year, if you’re exceeding performance, you slow down a bit’. You can do it; that’s how we did it for years.

“We’d have an argument [with commissioners] about whether you could actually [limit activity] without harming performance or standards. Generally, they were sensible conversations.”

Back for good?

Clearly, Sir Jim, given the 50 per cent cuts order, also thinks all this can be done with much less staffing than ICBs currently have — although “core finance and contracting” is among the functions ICBs have been told to “maintain or invest in”.

This is not any newly dreamt-up “strategic” version of commissioning — it is basic, vanilla commissioning. 

It is, however, a bit premature to declare NHS commissioning entirely alive and well.

The current enthusiasm may well be a convenient stopgap for recovery and transition, and to define ICBs while cutting them back. The changes in population needs and healthcare tech, which have pushed services globally to join up their models, haven’t gone away. Compared to the 2000s, there is a vastly bigger gulf between what commissioners can afford and what they need. 

If 42 are slashed back and merged down to about 25, as many expect, other means will be needed to properly manage local primary and community services.

It is certainly not the only lever for change on the list for the 10-Year Health Plan. There will be new performance management measures from new regional teams. The promised Health Bill will — believe it or not — major on devolution and system-led improvement. Providers are waiting in the wings to have another go at developing ACOs/local care organisations. And the reset Care Quality Commission is not going anywhere.