Many reforms must rest on well-supported commissioners. Specialist services and agencies serving clusters of primary care trusts mean help is at hand, reports Daloni Carlisle

Commissioning. We know its importance. But how many of us know just what it is or how to do it well? These are not rhetorical questions. As the NHS Confederation's 2007 report The Challenges of Leadership in the NHS spells out: 'Commissioning remains an area of concern especially as it is regarded as the mechanism through which many of the improvements to the NHS are driven.'

Generally it has suffered from a lack of investment compared with, say, the money poured into helping acute trusts move towards foundation trusts.

Some strategic health authorities have done good work, according to the report, but it will take time for extra training and skills to permeate the whole service.

That could be about to change. Today a wide range of work is in progress building commissioning capacity and capability. It comes from the Department of Health, SHAs and primary care trusts themselves.

The arrival of Mark Britnell as DoH commissioning and system reform director general was a turning point, in the view of NHS Confederation PCT network director David Stout.

'He has come in with the ambition to reform and re-energise around commissioning in general,' Mr Stout says. 'It is a fundamental requirement of a strong NHS.'

Underway now with a range of stakeholders including the DoH, SHAs, PCTs, the NHS Confederation and others is some work to describe 'world-class commissioning'.

'There is a relatively good consensus around this but it has not been formalised,' says Mr Stout. 'We want to set out a document that captures the aspiration of where we want to be, to tell the story of why it's important and what it looks like and develop the processes to get us there.'

The next part of the jigsaw is the debate about whether there should be some sort of compliance regime for PCT commissioners equivalent to Monitor for the foundation trusts.

'We do not want just to define world-class commissioning but define a means of delivery,' says Mr Stout. 'If you are a PCT that is delivering it, could you get some sort of earned autonomy?'

Work on this is likely to be still at the discussion stage in October, as far as PCTs are concerned. But elsewhere, more concrete developments are in place. PCTs in London, Manchester and the West Midlands are all working collaboratively to set up commissioning support services.

They are at various stages of development but all have a common feature: providing high-quality data to PCTs and practice-based commissioners.

This summer saw the formal launch of the Greater Manchester commissioning business service, a collaborative venture between 10 PCTs designed to offer practical support.

It has been several years in development, explains chair Tim Riley, who is also Tameside and Glossop PCT chief executive.

A germ of an idea in 2001, it was developed through 2005 with input from US health insurance guru Leonard Schaeffer and visits to US health maintenance organisations Blue Cross Blue Shield.

'We basically went over there to steal their ideas,' says Dr Riley. 'We learned that we needed much more definition and detail about where our population is and who our patients are. We needed to understand what was happening to them subsequent to referral. What choices were being made? What role did the referrer have in that?

'We also wanted to do some fairly simple economic stuff around coding. At the start we did not know how much was being spent on administrative errors, such as coding for male pregnancy.'

The PCTs decided to site the commissioning service within the Association of Greater Manchester PCTs. It would have a chief executive and board as well as a small staff and would house the tactical information service, providing high-quality data to PCTs.

Each PCT would be a shareholder and would be able to pick and choose services designed to support the entire commissioning cycle.

'It's not dissimilar to a company offering a range of products and services that PCTs can buy in,' says Dr Riley. It has a staff of four, received£500,000 to set up and will generate its income through charging shareholders - but will provide a dividend back to them if it creates a wider market for its services.

In the West Midlands 17 PCTs have pumped£3m a year into a commissioning business support agency with a staff of 43, launched in April this year.

London's 31 PCTs are in a much earlier stage of development but appear to be looking at a health informatics service.

Health informatics is the most basic service provided. West Midlands commissioning business support agency director Paul Taylor says: 'This is the pointy head, nerdy end of things. We take all the hospital activity data, process it, put it into a data warehouse, cleanse and validate it then feed it back to PCTs and practice-based commissioners as quickly as possible.'

These tasks were previously all done by PCTs with varying degrees of competence.

In Manchester, the commissioning business service is attempting from the start to support the entire commissioning cycle, from needs analysis through commissioning strategy, service and pathway redesign, market management and contracting, performance reporting and contract management.

So within the service is a collaborative commissioning team, which provides resources for lead PCTs commissioning services across the patch, for example cardiac or renal services.

There is also a procurement and market management team that provides support to PCTs on market engagement, tendering and the like.

Commissioning business service director Kevin Pritchard says: 'This team might work with individual PCTs around their market requirements for commissioned services or with the collaborative team.'

A performance contract management team is now beginning to work on centralised service-level agreement monitoring for PCTs.

One example of the work carried out for PCT clients is supporting commissioning of pre-operative screening, for example in the Greater Manchester Surgical Centre which has been running for a year and a half.

'PCTs are beginning to understand how to maximise the benefit of the service,' explains Mr Pritchard.

'They wanted to put in place a pre-operative screening process that would feed people into or away from the surgical centre as appropriate. We did a piece of work creating the service specification and aims.'

In another project, the commissioning service worked with PCTs to increase scanning capacity ahead of the ill-fated national contract with consulting firm Atos.

'We helped PCTs find a market provider and develop service-level agreements quickly,' says Mr Pritchard. 'We were able to get the capacity in and working very quickly.'

The strength of the commissioning service in both these instances was the aggregation of the PCTs, giving the ability to act collectively and quickly. Other projects have relied on the sharing of good practice, where one PCT can come and ask about expertise or existing work in other PCTs.

'It should lead to an acceleration of commissioning because people are sharing best practice,' says Mr Pritchard.

West Midlands commissioning business support agency has taken a different tack. A flagship development has been account management.

'We offer a contract management service where we have a network of 20 account managers sitting between the PCTs and the trusts trying to manage the contracts between the two,' says Mr Taylor. They are trust-based and can answer questions from any PCT contracting with that trust. It's a model taken directly from the best in the private sector.

'It's a real bonus for PCTs as it gives them a specialist within the trust,' says Mr Taylor. 'It's good for the acutes too. I used to be a finance director and I know the frustration of not being able to talk to PCTs 20 miles away. Now they can.'

It is working really well, says Birmingham East and North PCT director of redesign and commissioning Andrew Donald.

'That sort of brokering is really important,' he says. It is what he spent most of last year doing and, frankly, it is not where his energies should be concentrated. He is keen for the agency to get the 'widget part right first' and demonstrate value to PCTs on data provision. But as a board member, he is equally keen to drive through a vision that would see the agency take on a much wider role.

'I am working on testing a scenario planning tool for the NHS Institute. You put in some scenarios and it will do the capacity modelling for you based on disease prevalence. It's a good product but my commissioning team do not have time to do that work. It would need to be a partnership between various bodies and that's where the CBSA can provide capacity.'

Within Greater Manchester, PCT chief executives are enthusiastic about the CBS, although cautiously so.

'It has some really interesting aspects. It's a question of what we want to use it for,' says Heywood, Rochdale and Middleton PCT chief executive Trevor Purt.

'I would like to see it develop into an organisation which undertakes a contracting and procurement role on behalf of its constituency PCTs. By moving to an agreement where organisations use the CBS to negotiate with providers, we would begin to identify which acute trusts are effectively delivering on their contract.'

Bury PCT chief executive Steve Mills adds: 'Certainly it is bringing value because up to now we have not had the level of intelligent analysis that it is providing, but the real benefits are probably a couple of years away.

'It will enable us to test out whether the Framework for procuring External Support for Commissioners will bring productive results to support commissioning.'

This is just a skim over the surface of two exciting devlopments. Both Greater Manchester's service and the West Midlands support agency have plans for developing and using real-time data and other exciting projects. Will they bring the promised benefits and help see commissioning mature? Watch this space,

David Stout sees these and other developments as a sign that commissioning is maturing.

'My take is that commissioning is not very old,' he says. 'Until recently we did not have the new general medical services contract, payment by results, and tariff. We didn't have patient choice and we did not have a lot of the techniques we are starting to develop.

'We are now seeing a new generation of commissioning activity and we now need to move from pockets of good practice to consistency.'

Commissioning in the capital: the London provider agency

The main aim of the London provider agency is, confusingly enough, to build on the commissioning capacity and capability of the capital's primary care trusts.

'The capacity and capability of commissioning is the big concern,' explains its new chief executive Malcolm Stamp.

'The NHS in London spends£13bn a year and commissioning needs strengthening if it is going to sort out a strategy for London that addresses some of the very needy areas.'

Hence the agency, an arm's length body that started working in June this year. It has a budget of£1.8m, a staff of four and an independent chair, Lord Warner.

The basic idea is that it will take on a number of work areas, thereby freeing PCTs to concentrate on developing commissioning, running in parallel to other strategic health authority work on developing commissioning.

Among the agency's work areas is the performance management of 33 trusts, moving them towards foundation trust status. 'As part of that we have introduced a performance management framework consistent with Monitor's,' says Mr Stamp.

The agency will also take on monitoring the Healthcare Commission reports on all London trusts.

Another of its major jobs will be to lead on various aspects of the new healthcare strategy for London being developed out of health minister Lord Darzi's report on the capital. So, for example, it will develop an estate strategy to support the new models of service provision that are likely to develop over the next few years.

It will also be responsible for driving the distance between PCT commissioning and PCT provision. Mr Stamp says: 'We hope this will allow PCTs to focus on commissioning improved health services.'

Currently, the LPA is piloting a diagnostic tool to start to get a handle on what PCTs are providing that will help kick-start the debate on how best to get that distance.

'I don't think there is any one model on this and we have been very deliberate not to come off the fence on that,' says Mr Stamp. 'We may see social enterprise or not-for-profit organisations coming in. It's about what works best.'

Some clues to Mr Stamp's thinking might be gleaned from his background. He was chief executive of Cambridge University Hospitals foundation trusts in 2004 before leaving the NHS for New Zealand, where he managed Waikato district health board.

There he has been involved in contracting with non-governmental organisations to provide health services, notably forensic psychiatric services for the Maori population.

Mr Stamp is reluctant to say which of these pieces of work is the biggest challenge. 'Without doubt it's the whole package,' he says. 'To support commissioning and implementation of what will be the NHS London strategy we have to move this mountain of work quickly.'

Nor will he be drawn on whose idea this was. Background briefers attribute it to David Nicholson when he was briefly in charge of London before moving into the Department of Health as NHS chief executive. They suspect this may be the shape of things to come elsewhere.

Of this, Mr Stamp is doubtful.

'London is big,' he says. 'It's a large chunk of the NHS. I would be surprised if each SHA needed an agency like this.'