10 priorities for commissioners from April

Next week the new commissioning bodies take full control and take on extensive responsibilities. Candace Imison sets out what their top priorities should be

On April 1 the three new sets of commissioning bodies will take control of over £100bn of public money: clinical commissioning groups, local authorities and NHS Commissioning Board (soon to be NHS England).

‘Active engagement of patients is a common thread to all these priorities’

Their goal, working collaboratively with health and wellbeing boards, will be to improve the health of the population and the performance of the health system, as measured by the NHS and public health outcomes frameworks. It’s a daunting task, especially at a time when the NHS has just moved from a time of plenty to an extended period of famine, and social care budgets are facing year-on-year cuts.

It’s also a vital task, given the current health and social care infrastructure and models of care will fail an ageing population with a growing burden of chronic disease. It’s a challenging task while developing a new organisation, and new relationships within and across organisations, at the same time. It would be easy to be swamped by the scale of it. It would be easy to endlessly react to the next “latest thing”.

At the King’s Fund we have identified 10 priorities for commissioners(see slideshow, below). The evidence suggests these priorities will help commissioners address the challenges faced by the NHS and drive improvements in outcomes. These are:

  1. Active support for self-management
  2. Primary prevention
  3. Secondary prevention
  4. Managing ambulatory sensitive conditions
  5. Improving the management of patients with both mental and physical health needs
  6. Care coordination through integrated health and social care teams
  7. Improving primary care management of end of life care
  8. Medicine management
  9. Managing elective activity − referral quality
  10. Developing an integrated approach to urgent and emergency care

Common themes

There are several common themes across the 10 priorities. A more systematic and proactive management of chronic disease is needed. This will improve health outcomes, reduce inappropriate use of hospitals and have a significant impact on health inequalities.

Patient empowerment − patients are arguably the greatest untapped resource in the NHS. The active engagement of patients, involving them in decision making and providing support to help them manage their conditions, is a common thread to all these priorities.

A population-based approach to commissioning − a key challenge for commissioners is to direct resources to the patients with greatest need and redress the “inverse care law”. Clinicians involved in CCGs will need to shift their focus from the patients that present most frequently in their practice to the wider population that they serve.

More integrated models of care − from “virtual” integration through shared protocols to integrated teams, and in some cases shared budgets and organisational integration. A striking feature is the degree to which the 10 priorities call for change to primary care. Another key feature is the need for collaboration: collaboration between commissioners, and collaboration between commissioners and providers.

Performance and accountability

As the recent work by the Nuffield Trust has shown, collaboration is not enough. It needs to be backed up by strong “transactional” commissioning. It’s not just a question of “doing the right thing” but making “the right thing happen”. Much of what we describe has been known for years but is not done systematically. The potential strength of GPs’ engagement in commissioning is that it will drive more meaningful clinical dialogue and change across primary and secondary care.

There will be a need to invest heavily in developing strong commissioning organisations and good working relationships across the health system if they are to exploit this advantage. In our view, there are three important areas that require developing: organisational development, transactional skills and transformational skills.

Establishing robust clinical and organisational governance not only underpins high-quality performance but also ensures the accountability that is essential for CCGs as the guardians of £66bn of public money and undertaking transactions that are subject to competition law and regulation.

Commissioners will require a high level of technical competence to undertake the “transactional” elements of commissioning. They have at their disposal a range of market mechanisms, such as putting services out to tender.

‘High-quality commissioning requires extensive collaboration and the ability to work with partners across the system’

Used creatively and well these can facilitate novel and more integrated models of care. Used badly, they can result in fragmentation. Key to their success will be how commissioners use the various contractual levers available, such as incentive payments (commissioning for quality and innovation), risk-sharing arrangements and innovative, outcome-based contracting.

Commissioners will also need strong information management and technology capabilities to help them understand variation in outcomes, and to use this data to hold providers to account. For many CCGs, these transactional skills are likely to be provided to a large extent by commissioning support units. The importance of establishing effective relationships between these and CCGs cannot be underestimated.

Finally, commissioners will need the relational skills to deliver service transformation. High-quality commissioning requires extensive collaboration and the ability to work with partners across the health and social care system to deliver change. They will need to make progress in all of these areas if they are to rise to the challenge of transforming the healthcare system.

Candace Imison is deputy director of policy at the King’s Fund