Published: 10/04/2003, Volume II3, No. 5850 Page 42

By sharing knowledge and skills, primary care trusts can improve their understanding of commissioning. Andrew Donald discusses steps that have already been taken

Over many years, the NHS has tried different commissioning models, but has failed to find the best way to deliver outcomes for patients.

This may be because we have not really understood the concept of commissioning. It has then been difficult to put it into practice and virtually impossible to give any credibility to the process for the individuals involved.

The national primary and care trust development programme approaches primary care trust lead commissioning in the same way it does PCT development. It is not here to tell people what to do or how to do it. It works to share understanding between PCTs and to create an environment that allows the service to link commissioning to wider processes of contracting and service redesign.

The programme is working with PCTs to identify the knowledge, skills and behaviours they need to make commissioning work. It will shortly release outline commissioning competencies as part of a revised PCT competency framework.

We can already see a number of steps PCTs must take.

They need to make an informed assessment of their capability and capacity to commission effectively and arrive at a candid appraisal of what their short and long-term commissioning goals should be. This should inform how they engage with the diverse related policy strands (reforming financial flows, patient choice, section 11, foundation trusts, practitioners with special interests, and diagnostic and treatment centres) and the development support opportunities each may bring.

PCTs must have clinicians at the heart of the commissioning process and involve them in talks on service provision and development in the professional executive committee and other forums. PCTs that have taken control of the commissioning agenda have good relationships with their practices.

Commissioning cannot be imposed inflexibly from above. There needs to be open, continuous dialogue on referral practice, and the sensible level at which commissioning decisions are taken so they fit around the clinical needs of patients.

PCTs must concentrate on fewer commissioning goals, not more. Of course, all PCTs are under pressure to make everything a priority so there is a challenge for boards to keep their organisation focused. Chairs and non-executive directors will be true friends to their executive colleagues if they remind them of the commissioning objectives to achieve this year - before going on to do more in subsequent years.

PCTs must have robust information before they can set their sights on these targets. Is it any use for PCTs to continue their scattergun approach to commissioning decisions when most healthcare resources are consumed by a small percentage of the population? Mutual healthcare organisations in the US have shown what can be done with more sophisticated analysis of existing data.They can teach us about correlation of detailed information on populations, service activity, cost and health gain to highlight the strategic opportunities to maximise patient benefit.

PCTs need to work through the quality issues, measuring standards and patient outcomes to improve performance in the next cycle.Here again, there is the challenge ofmarshalling and managing information across functions and organisations that have traditionally lived in their own discrete information worlds.

But there is an additional dimension.

Once it has the evidence, can the PCT act on it? How prepared is it at a corporate level, and in its relations with practices, the NHS and other partners, to live with the consequences of tough decisions about the future of particular commissioned services?

PCTs may also need to consider radically different ways to commission.

They could require expertise and experience that is not present in their own organisation.This may be through networks or other arrangements that ensure integration of service provision through care pathways. It may involve agencies or third parties with a track record and base of expertise.All these processes touch every part of the PCT.They require clinicians and managers to share experience and practice, within their PCT and across PCTs.That is why the national primary and care trust development programme has invested heavily in area facilitators, PEC chairs and other PCT networks, stakeholder groups, development events and a website.

This support will soon be carried a stage further when mixed teams from every PCT will have the chance to work and reflect on the shared challenge of radical change with two other PCTs of their choice and a world-class facilitator.We know that many PCTs want to use these action learning sets to tackle the challenges of commissioning.

Andrew Donald is director of operations, national primary and care trust development programme.

He will speak on 'Developing effective joint commissioning arrangements'at the PCT Commissioning conference in London, organised by HSJ on 30 April.

Other speaker topics include effective capacity planning, performancemeasurement models, financial flows and involving local communities.

For more information, call EC Conferences on 020-7505 6044.