'A trust has never pointed out where the tariff gives a generous cross-subsidy to other activity'

'PCT commissioning quality: freefall continues' was the summary of responses to the last HSJacute chief executives' barometer (page 25, 8 June), but when my acute colleagues express such concern, what do they really mean by 'quality'?

Commissioning has long been the poor relation of the healthcare marketplace. It didn't even have a name in the NHS for the first 40 years, being part of an entirely provider-dominated system in which the money flowed seamlessly from the Department of Health to directly managed units. In fact, it was flowing a little too fast and with too little clarity about its impact for the then Tory government's liking.

Hence 1990, the purchaser-provider split and the introduction of self-governing trusts; for the first time the NHS had to contract for services and make an attempt to count who was using them.

Commissioning was born and for the first time we would pay attention to health improvement rather than just treatment. In addition came the expectation that we should look for quality and value from providers, not just local availability.

Yes, we have been working on this agenda for well over 10 years now, but commissioning remains under-developed, not least because commissioning organisations are facing their fourth reorganisation.

Health improvement remains the core responsibility and driver for primary care trusts and as the contribution of organised healthcare to this agenda is about 30 per cent, it requires PCT managers to spend much of their time in activities largely invisible to acute trust colleagues. That 30 per cent can come disproportionately from systematic chronic disease management based on rigorous identification, systematic treatment and regular recall in primary care.

But this requires investment in primary care capacity, capability and capital. The historic focus of the NHS for primary care has been demand management of elective care in hospitals, but increasingly the competence in primary care and availability of new pharmaceutical interventions has combined to make the commissioning of primary care itself a matter of millions of pounds of expenditure.

Care close to home is inevitably a partnership of both commissioning and provision, involving not only local government but housing associations, community groups and third sector providers. This network of care is complex to commission and even more complex to quality assure, typically involving patients who are at high risk of abuse.

We must tap into the considerable knowledge and commitment of patients and their families. As Derek Wanless noted, self care is crucial to sustaining a publicly funded service. The work of Kaiser Permanente shows that education is the best prescription and a highly cost-effective intervention, but it is not an approach which has been funded and so still requires new money, diverted from elsewhere.

If 70 per cent of health improvement is about social, economic and educational status, PCTs must seek to maximise value from neighbourhood renewal, source land to develop community infrastructure, collaborate with children's services in relation to building healthy habits early.

Increasingly we are players in local strategic partnerships to develop healthy cities encompassing concerns with economic performance and regeneration, community safety, and the public sector as often the major employer in the local community.

In June, Foundation Trust Network director Sue Slipman said: 'We've clearly got PCTs that are not yet fit for purpose and do not quite understand their role' (news, page 13, 8 June) but PCTs have more to do than just handing over money to hospitals, and under payment by results we have new tensions to cope with: a tariff based on an algorithm of historic inefficiency, and coding which enables trusts to charge for a whole range of co-morbidities which cost no more than ever.

They are keen to note where the tariff does not cover costs, but I've never been contacted by a trust pointing out where the tariff gives a generous cross-subsidy to other activity.

Consultant-to-consultant referrals are the largest growth area in the NHS; as demand management bites, hospitals start to refer to themselves instead, undermining the gatekeeper role which keeps the NHS one of the world's cheapest health systems.

The challenges of the white paper and 18-week target are just the latest to require a total rethink of care models, but the culture and public expectations remain hospital dominated - acute trust chief executive officers are paid more and financial systems reward activity which has not been commissioned.

And PCTs provide services, which enables us to have direct relationships with the public. It gives us intelligence on what is happening in acute care - we now know which wards produce the most bed sores - and enables us to rapidly put in place alternatives where local trusts try to maintain the status quo.

So an effective commissioner will be a) spending much of the time on work outside of the scope of the local acute trust and b) challenging that trust on activity and attribution. Both activities which potentially set commissioners and providers at loggerheads, although the best of both work constantly to keep talking and collaborating in the face of potential fallout. We need to:

  • align local organisational goals to be concerned with the performance of a local health economy rather than individual organisations;
  • give and receive consistent strategic messages and performance management from the centre (and it is not helpful to have parallel systems for foundation trusts and other NHS bodies);
  • exposure and validation for the range of activities led by PCTs outside of hospital commissioning.

Most importantly, this will deliver care outside hospital and maximum 18-week waits for care within it.

Sophia Christie is chief executive of North and Eastern Birmingham PCTs and a new regular columnist forHSJ .