Contracting to commissioning: why does NHS change take so long?

The NHS has a tough challenge: to meet growing needs of an ageing population while improving outcomes, quality of care and reducing health inequalities. Moreover, it has to do all this while meeting anything up to a £30bn funding gap by 2020-21.

The NHS Five Year Forward View sets out how this might be achieved. The report from Simon Stevens also notes that the NHS is “on the hook” for not taking prevention and public health more seriously in the past. 

So how will the NHS shift more resources, while tackling a deficit, into prevention activity whilst meeting the current needs of an ageing population?

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Seismic shift

What is now certain is that the challenges ahead cannot be overcome by tinkering at the margins or by dumping all the challenges on the acute sector. 

A transformational shift is required, from contracting services to commissioning them, driving more care and better outcomes from all available health resources.

What is the difference between contracting and commissioning?

‘Future decisions require agreeing activity, rather than thinking about needs’

In a survey carried out by the University of York and published in 1997, NHS purchasers said contracts were focused on activity and the exchange of money, whereas commissioning was more about reshaping, modelling and planning services.

This is certainly our experience of hearing care in many regions, where often contracting in the NHS involves basing future decisions on what was done last year.

It is about agreeing activity, rather than thinking about needs. It is about picking a type of payment mechanism – for example, block or cost and volume – that is familiar and acceptable to commissioner and the provider without thinking about outcomes for service users.

It is about tinkering with a failing system in the hope that problems will fix themselves. It has also attracted its own distorting discourse – for example, “overperformance” which can often mean “meeting need”.  

Rethink purchasing

For commissioners however, apart from the money issues, the traditional approach to contracting is relatively effortless - a programme of activity  is planned and this is likely to be repeated the following year; unless threatened by a financial challenge or serious quality failure.

The downsides of this approach are borne primarily by individuals, populations and frontline clinical staff all being increasingly short changed in terms of service, outcomes and stress.

‘Use contract mechanisms strategically to deliver benefits for patients, not providers’

Commissioning in contrast involves rethinking the purchasing of healthcare. It is about using epidemiological data to plan services based on need, not historical activity.

It is about using contract mechanisms strategically to deliver benefits for patients, not providers.

It is about using language like “unmet need”.

It involves not ducking issues, such as, decommissioning failing services when providers refuse to address the root causes of problems.

It is, of course, incredibly difficult. It also leaves commissioners with data on outcomes, activity and costs which they must then also analyse to improve services.  

Hearing should be higher priority

What difference does it make?

NHS adult hearing services illustrate what happens when services are contracted for rather than commissioned. 

Poor contracting has resulted in predictable and avoidable problems not being addressed in time and hence older people being let down, and paying the price time and again. 

‘Adult hearing loss is the fifth leading cause of burden of disease’

The story is simple. Considering adult hearing loss is noted as being the fifth leading cause of burden of disease in the region by the World Health Organization, the NHS spends relatively little on hearing problems.

It has historically been a low priority for NHS commissioners when things are going well.

But equally it is an “easy” target for cuts when the going gets tough. Therefore, it is not surprising that adult hearing care has in the past has been labelled the Cinderella amongst “Cinderella services”. 

Today, with North Staffordshire, and Northern, Eastern and Western Devon clinical commissioning groups considering cuts to adult hearing services, there remains a risk that the service will reverse any progress made in recent years.

Chronic failure

NHS adult hearing care has a long and chronic history of systems failure. 

Failure to plan capacity or properly resource adult hearing services to meet need has been well documented by the Royal National Institute for the Deaf and others since 1983.  

The root cause rests with the various purchasers of NHS hearing care over the last three decades.

Put simply, adult hearing care has never mattered enough for the NHS to “fix it” – bar the sporadic pressures caused by damming reviews in 2000 and 2007.

A brief historical review will show that the institute (now known as Action on Hearing Loss) and others have found a lack of instructions for patients, a lack of follow up care, and a lack of individualised care plans have resulted in hearing aids “ending up in drawers”.   

‘The root cause rests with the various purchasers of NHS hearing care over 30 years’

The RNID – supported by wider sector – has long called for hearing services to be commissioned properly, and in recent years the Audit Commission, the Health select committee and the Department of Health have accepted the  case.

Unfortunately, each time the train for reform has run out of steam and, in characteristic fashion, the NHS has slipped back into its old ways and patients have lost out.

The introduction of the “any qualified provider” initiative for adult hearing services had the potential to deliver what the Action on Hearing Loss had been calling for since 1988: a community based hearing service for people with age related hearing loss.  

However, its aims have obfuscated by shroud waving and unfounded claims.

One remarkable claim was that the AQP pathway was more costly per patient - a view that can only be explained by a failure to read the DH implementation pack.  

The simple fact is that the AQP adult hearing pathway was based on a 10 per cent reduction on tariff combined with an improved specification for patients and commissioners. It was a pre-made commissioning pack to get more for less; not a contract for doing more of the same.

Take that step

Many commissioners also overlooked the fact that the new tariff for adult hearing care was designed to cover a comprehensive care pathway for at least three years with defined quality indicators.  

The new offer was a real innovative step for the NHS and especially for adult hearing care.

In fact, in using the tariff mechanism to derive prices and setting quality indicators as well as a three year pathway, the 2012 AQP specification delivered what experts had recommended in order to encourage cost efficiency and deliver high quality care.

The tragedy is that these gains for patients, populations and the NHS (better outcomes at lower costs) are now once again at risk of being lost owing to lack of attention by CCGs and the creation of distorted playing fields for providers – for example, varying contracts based on provider type rather than patient characteristics.

We have spent many hours analysing how CCGs procure adult hearing care across England. There are pockets of commissioning but many more areas where this service is still simply contracted for.

For example, we analysed 28 CCGs that relied on a block contract for adult hearing services in 2013 and:

• 0 per cent used commissioning for quality and innovation;
• 75 per cent held no data on waiting times;
• 86 per cent held no data on number of hearing assessments (despite these been readily available in reference cost data);
• 0 per cent had no active process to monitor quality; and
• of the 7 per cent that did report using outcomes data, all used waiting times.

If the NHS is to meet the challenges ahead this has to change.

Adult hearing services are predictable and easy to plan for. Epidemiological data are readily available and so too are data on the prevalence of other causes of hearing loss in older people.

There is even an online tool that will help commissioners view their region and assess the risk of significant unmet need and hence manage any transition to a community based model.

The only reason to continue contracting rather than commissioning this service is because it is not considered sufficiently important.

‘It’s time for the NHS to purchase outcomes for patients’

Given that the WHO has called for us all to rethink hearing care as enablement rather than disablement, that is remarkable.

If we are to really support active ageing and independence in older life this is one service that, if done well, will reduce system wide demand and costs.

Commissioning has to be based on evidence and needs, not past activity, relationships and institutions.

It is time for the NHS to purchase outcomes for patients and there are providers ready to deliver that.

It remains to be seen whether commissioners, including NHS England, accept that offer or whether the NHS Five Year Forward View, like many strategic documents before, is not strong enough to escape the gravitational pull of inertia within the NHS when it comes to really supporting people ageing well.

Harjit Sandhu is head of policy at the National Community Hearing Association