How to commission high quality, low cost health care

The 152 new primary care trusts are tasked with becoming strategic commissioning bodies. This means they must procure a range of provision for local people, which meets their health needs and delivers health improvements, by securing the highest value for their limited money. Stating the task is easy. Delivering it will require significant change, and for talents across the whole health and social care system to be harnessed.

Many PCTs are focusing on demand management of their acute contracts, and thorough contract management to prevent any up-coding or errors. With the need to get NHS finances in order, this is understandable, but it will deliver for one year only and should be part of the day job. To thrive in the long term, each PCT needs to support new players to creatively redesign the services it commissions.

Lean production, especially the way Toyota does it, is on many NHS agendas at the moment. But as Steven Spear put it in the Harvard Business Reviewin September 2005, 'what sets Toyota aside is not their portfolio of existing solutions but their ability to generate new ones repeatedly'.

The NHS needs to create environments where the creativity that drives service transformation can thrive. In the private sector people are expected to develop new solutions to problems, not just work around them. Some companies even allow unstructured time to be set aside for innovation. The NHS culture has not in the past encouraged this as part of normal business.

Most innovation will come from social enterprises, practice-based commissioning and other clinically led approaches, new provision arising from this, and co-production with customers. All these networks are asking the same questions:

How can we get support to take off and where can we get it from?

• How do we as potential suppliers compete for market share?
• How do we encourage NHS chief executives to invest in us?
• How do commissioners enable local ownership and growth?
• How do we market our achievements and outcomes in a way the NHS understands?

These are questions of market management, which apply equally to small social enterprise providers and new providers emerging from practice-based commissioning. The answers need to be shared across networks.

As 'macro' commissioners, PCTs must be clear about what they want to commission. They must provide the data to benchmark services, and measure change against clear outcomes. They should create a network of support for small enterprises and help them tap into it. New governance frameworks must be developed to provide safety levels which are comfortable for people in a co-production environment.

We want to keep people well at home. Small local initiatives -generated by local people and social entrepreneurs, often run by social enterprises - can make a targeted difference in health status. They can reach the people other initiatives can't reach.

Similarly, alternative services working with patients and relatives can find different ways to manage health needs. For example in Arizona, the commissioners found paying families to provide care was more reliable than paying agencies. Governance issues were dealt with by contracting a healthcare agency to supervise and train family members.

We need to use networks to spread the word about what works rapidly across the system, so new commissioners can quickly start commissioning whatever is appropriate for their area.

For new providers, PCTs must not be a 'dead hand' limiting creativity with bureaucracy. For organisations still in a state of flux this will be a considerable challenge.

Felicity Cox is a Networks associate at NHS Networks