Two healthcare management experts lock horns over whether the drive to raise the standard of commissioning really can transform the quality of care

In an HSJ opinion piece on 6 March, Frontline Consultants director John Deffenbaugh said world class commissioning could be achieved if its success was driven by the front line. But in a letter to HSJ two weeks later Chris Ham, professor of health policy and management at Birmingham University's health services management centre, called Mr Deffenbaugh's comments a "triumph of hope over experience".

Which is right? We invited them to have a frank exchange of views over the likelihood that the NHS has the evidence base and skills to create a system of commissioning that will be the envy of the world. Chris Ham kicks off their debate.

To: John Deffenbaugh

Subject: World class commissioning

Like you, John, I hope commissioning will really deliver improvements in health for the population and improvements in care for patients. Unfortunately, previous NHS experience and international evidence do not give grounds for optimism.

Commissioning was the weak link in the internal market in the 1990s and there is no reason to believe things will be better this time around. The reality is information and power in the NHS rest overwhelmingly with providers, making it difficult for commissioners to negotiate on equal terms.

A market in which sellers are consistently more powerful than buyers is never going to work well and it is a majestic triumph of hope over experience to believe otherwise.

My views have been reinforced by a rapid review of international experience which focused on Europe, New Zealand and the US. The evidence clearly demonstrates that in none of these systems is healthcare commissioning done consistently well. There are examples of innovation and good practice in all systems, but the conclusive view is of the challenges facing commissioners and the obstacles confronting those who have set out the ambitious aim of making commissioning in the NHS "world class".

These obstacles derive from the complexity of healthcare, including the difficulty of specifying and monitoring contracts to improve performance. Policy makers everywhere have hugely underestimated the scale of the challenges involved and this is why I am doubtful that the current direction of NHS reform in England will deliver.

As a health policy analyst, the currency I deal in is evidence rather than hope or belief. And when the emperor is clearly walking naked through the streets, there is surely a duty to point this out.

Chris

To: Chris Ham

Subject: Re: world class commissioning

I wholeheartedly agree, Chris, on the need to point out the evidence and the implications for policy. I guess my approach in contrast to yours is that of a practical consultancy perspective. While I am not saying ignore the evidence, I am questioning the practicality of implementing what it says at this time.

I am a wee bit more optimistic on the prospects for commissioning this time round. It is now seen as "mission critical" to the NHS's success; it is fully embedded in policy and has the resources to back it up; it has tools such as the framework for external support to leverage change; a definition (though much needs to be done to get past the logo and acronym) and it has a champion [NHS commissioning director Mark Britnell] - who is, interestingly, an ex-provider. Providers may have information but with increasing transparency its power will reduce. Commissioners have cash. OK, they haven't used this lever effectively in the past and can now only use it at the margins, but this power will increase - not through a rules-based approach as the framework proposes, but because they will work smarter with their providers.

John

To: John Deffenbaugh

Subject: Re: Re: world class commissioning

John, I am glad we agree on the importance of evidence. What is clear from the literature is that high performing organisations tend to be those that combine commissioning and provision and engage clinicians fully in the quest for improvement. Examples include Kaiser Permanente and the Veterans Health Administration in the US. These organisations understand the difficulty of commissioning care from external providers and this explains why they have chosen to internalise commissioning.

In the language of economists, they put the emphasis on "making" rather than "buying" care because their experience shows this is likely to be most effective.

Economists have developed a whole branch of theory to analyse these "make or buy" decisions and have shown why complex transactions (such as healthcare) lend themselves more to vertical integration than commissioner/provider relationships.

If we are to act on the evidence rather than ignore it we must figure out a way of translating this learning into the NHS. My view is that this has to be done without a further major structural upheaval. One way forward would be to build on practice based commissioning and to offer a total budget to networks of practices able to show they have the ability to take this on. The aim should be to migrate from practice-based commissioning to multispecialty-based commissioning, in which practice networks would work closely with specialist teams to both commission and provide care.

As in the best US organisations, clinicians would be in the driving seat and the offer of hard budgets with full profit and loss responsibility would be a powerful incentive to galvanise change.

What does your practical consultancy perspective have to say about that?

Chris

To: Chris Ham

Subject: Re: Re: Re: world class commissioning

We agree on the avoidance of major structural upheaval, Chris. Hence, my emphasis on primary care trust renewal from within in order to achieve change, rather than a further top-down diktat.

While your evidence would suggest "going to" something, I do not think there is yet the evidence and therefore the impetus among policy makers that the emerging design of commissioning as a standalone entity is worth the cost of "moving away" at this point. While the NHS has toyed with purchasing/commissioning since the start of the 1990s, it is now getting real. Hence the whole movement of world class commissioning. While I think we should give it a try, I am not sure where this will end up. For one thing, what is "world class"? For another, you would say the evidence shows it is bound to fail anyway. If this indeed is the case, the impetus for change in the direction you propose needs to be built up and people need to be convinced of the need for what in reality is something totally different from what we have now.

The change equation maybe provides a guide on how to make this happen: three elements together need to be greater than the economic, organisational and other costs of change.

There needs to be a clear and positive vision for the future, dissatisfaction with the current situation and knowledge of the first steps. So the vision of what you propose needs to be compelling, there needs to be a recognised failure in the current model of commissioning and there needs to be awareness of how to put your proposal into place. There is a challenge for you - translating evidence into locally based pilots that show the benefits of vertical integration, compared with the current model. This brings our two approaches together.

But in the UK, I am wary of putting clinicians, by which I mean doctors, in charge. I judge their current ability to act as effective allocators of resource - in vertically integrated structures or through practice based commissioning - as requiring much greater experience and maturity in order to do a better job than the existing commissioners. Comparisons with the US must take into account the totally different nature of the systems - private profit there versus nationalised here. When you suggest full profit and loss responsibility, do the doctors get the profit?

John

To: John Deffenbaugh

Subject: Re: Re: Re: Re: world class commissioning

What I am proposing is already happening in some places, John.

I have just finished writing a new report for the Nuffield Trust, Integrating NHS Care: lessons from the front line, describing examples of clinically integrated care in Bolton, Birmingham and Surrey. These examples have arisen from the initiative of medical leaders working with managers to find ways of improving care to patients.

In Bolton, a managed diabetes network has been established; in Birmingham, Heart of England foundation trust and Birmingham East and North primary care trust have integrated care in a number of areas by adapting lessons from Kaiser Permanente; and in Surrey, the flexibilities in primary care contracts have been used to provide a wider range of services closer to home.

I believe those involved in Lord Darzi's next stage review understand the value of what is happening in these areas and want to see more examples of integration emerge in the future. This is really encouraging as long as the Department of Health resists the temptation to prescribe a single solution - God forbid we go down the path of "world class integration"!

We will have to disagree about clinical leadership. All of the evidence of which I am aware points quite clearly to the need for clinicians to be centrally involved in developing new service models and controlling budgets.

The models in Bolton, Birmingham and Surrey are living examples of doctors taking the initiative to achieve closer integration and doing so in partnership with managers. The experience of these areas is reinforced by the experience of integrated delivery systems in the US.

Laura Tollen's recent report on the quality and efficiency of care identifies strong physician leadership as a key characteristic in these systems. Add it to your reading list. If clinicians (and yes this will often mean doctors) are not at the heart of attempts to improve patient care and system performance, then we really have lost the plot.

Chris

To: Chris Ham

Subject: Re: Re: Re: Re: Re: world class commissioning

Chris, getting politicians to accept diversity in structures for provision could be a deal-breaker, from both our perspectives. The cry of "postcode lottery" steers things towards uniformity. Hopefully, the examples you have cited and others that emerge will show the benefits of taking a variety of approaches to meet the same end. We now see this across the different systems in the UK.

Your currency of evidence, however, will still need to convince politicians and policy makers in England. My currency is also optimism, which is probably why I have voted for Barack Obama.

I agree wholeheartedly on the beneficial role of clinical leadership, but instead of following the US physician-in-charge approach, maybe we should get "clinician" to actually mean clinician. Rather, my issue is the current preparedness of clinicians to take on this central leadership role. Much development is required and I anticipate the Darzi review will put this in place.

So we appear to agree on some central issues - the benefits of evidence, the role of clinical leaders, the need to avoid major structural upheaval - with our differences about how to bring about change. I think commissioning must be allowed to run its course, which was set by policy makers like yourself when you were in the Department of Health. I think the case for change will need to be built on more than evidence - there may be rather more hope and belief in this conviction that evidence will hold sway than you are prepared to acknowledge.

In addition will be the work of innovative leaders, using many practical interventions to do things differently, influencing others and building coalitions to underpin and sustain change.

John

Find out more

Health Care Commissioning in the International Context: lessons from experience and evidence, Chris Ham, Health Services Management Centre, 2008, www.hsmc.bham.ac.uk

Physician Organization in Relation to Quality and Efficiency of Care: a synthesis of recent literature, Laura Tollen, The Commonwealth Fund, 2008, www.commonwealthfund.org/publications

Integrating NHS Care: lessons from the front line, Chris Ham, Nuffield Trust, 2008, www.nuffieldtrust.org.uk/publications

Feedback

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On 12 June HSJ is producing a supplement on world class commissioning including features on the commissioning assurance system and the fit between world class commissioning and clinical input. We are also hosting a conference on how to deliver the vision on 10 July. Speakers will include Department of Health director general of commissioning and system management Mark Britnell, DH Director of Commissioning Gary Belfield and national commissioning lead at the Care Services Improvement Partnership Janet Crampton.

For more details go to www.emapconferences.co.uk/worldclasscommissioning