Pursuing the rewards for world class commissioning unveiled by the Department of Health this week looks likely to prove a test of every PCT’s whole operational strategy. Helen Crump reports

Three months ago primary care trusts found out for the first time where they stood in the world class commissioning rankings.

As PCTs work out how to make sure they move up the list in order to have a chance at winning the freedoms unveiled by the Department of Health this week, the only thing everyone agrees on is that none is yet anywhere near world class.

Tribal director of commissioning services Derek Felton believes the gap between the best and worst PCTs is bigger than this year’s assurance process suggests - and growing.

He says: “The leading edge PCTs are getting further and further away from the trailing edge. It’s been a concern to us how big that gap is.”

Mr Felton says he has found some PCTs with more work to do on commissioning are “clamouring for a magic bullet”, but there is no miracle answer to getting up to speed - an overall transformation is required.

The emerging differences between PCTs’ approaches suggests genuine soul searching about the best way forward.

At the top end of the scale, Birmingham East and North PCT, which came first in HSJ’s world class commissioning league table, is driving forward a vision which involves tactical market stimulation, using competitive dialogue approaches and big pushes on innovation and clinical engagement.

Although the PCT’s goals quite closely match some of the competencies in the assurance process, chief operating officer Andrew Donald warns against relying on the competencies too heavily.

He says: “One of the dangers of this is that everyone becomes focused on the competencies for the competencies’ sake.

“The competencies should just be part of the way you do things. Some strategic plans were red rated because they bore no relation to reality. That’s more fundamental than meeting a lot of competencies.”

He continues: “For me it’s about people who are commissioners actually understanding what their jobs are about and if they [do] they will be competent in that and bring to bear all the knowledge they need to do the job properly.”

This means that where commissioners do not possess particular skills “they will know where to get them from”.

To this end, Mr Donald has recently gone cap in hand to his local GPs to build clinical commissioning expertise.

He says: “I’ve gone out to every locality, put my hand up and said: ‘We got it wrong, chaps. We think we need to look again at this, go through the process of reinvigoration and agree what practice based commissioning is for you guys.’”

By contrast, in Somerset, another top performing PCT, chief executive Ian Tipney is using the competencies to build a model to boost public health performance. He says his PCT “took the process of world class commissioning very seriously and realised how we could use [it] to really improve our own organisation and also drive forward the health inequality agenda”.

Action plan

“We were regarded as having a very systemised and rigorous approach to commissioning competencies,” he says.

“One of our challenges was how do you apply such processes to health and wellbeing? How do you take processes that we were judged to be good at, like commissioning services in the acute sector, and apply those to making real improvements in the public health agenda?”

Somerset PCT has devised a clear action plan for improvement against each competency.

Mr Tipney says: “If you’re working to [the competencies] in a very structured way, I think they’ll give you a very strong framework to take forward improvement.

“If you can really adopt the competencies and adopt them effectively, it makes you a much stronger organisation.”

Great Yarmouth and Waveney PCT faces a different set of challenges, as one of only two organisations to receive red ratings for its strategy, board and finance tests. Its then chief executive Mike Stonard told HSJ in March of his plans to turn around the PCT by next year

Mr Stonard has since gone and new chief executive Paul Zollinger-Read - also North East Essex PCT chief - has been in post for three weeks.

A new organisational development plan has already had “very good feedback” from NHS East of England, Dr Zollinger-Read says.

The PCT, which scored bottom marks in six out of the 10 competencies last year, is this time aiming for seven level twos and three level threes. Its strategy has already been adapted once but will be revised again for the next commissioning round.

Finance expertise

Dr Zollinger-Read says: “There is a lot of work to do on strategy. The strategy has been adapted but needs looking at.”

He adds that governance is a “main priority” and he is setting up a programme management office and bringing in new finance expertise.

He says: “The difference between good and poor performing PCTs is execution. Unless you get on and do it, check you’re doing it and if it’s not working [find out] why not, you won’t deliver.”

Mr Felton agrees: “In the least strong PCTs, commissioning levers are pulled in an inconsistent and often conflicting way by different bits of the organisation.

“The performance management team will go to a trust and say the quality needs to improve at the same time as the finance team goes in to talk about investment and disinvestment.

“Better performing PCTs are clear and cohesive about what they are seeking to change.”

With a consensus forming that, while there is no single right way to tackle world class commissioning, strategy is crucial, the challenge for strategic health authorities is to drive improvement without being directive.

NHS South East Coast has been providing its PCTs with development support, while trying to keep commissioners in the driving seat as far as their plans are concerned.

But it has identified some areas it wants its PCTs to work on, namely five year investment strategies, linking commissioning initiatives to strategic goals and clinical engagement, “not just responding well to practice based commissioning business cases”, head of commissioning and planning Oliver Phillips says.

Mr Phillips is impressed by PCTs’ progress, and is comfortable with the different approaches springing up.

“Most PCTs have combined their world class commissioning plans with their organisational development plans,” he says.

“One has integrated its world class commissioning plan with its operational plan. I was a little bit dubious until I saw it but I actually think it’s a really strong way to say we’re using the framework, strategy and outcomes to determine priorities.”

He adds that the latest strategic plans are “a quantum leap” ahead of last year’s.

“I’m genuinely pleased and almost surprised at the lack of cynicism and scepticism,” he says.

This is fortunate, as looming funding cuts will expose PCTs’ commissioning prowess, or lack of it.

NHS Confederation PCT Network director David Stout says PCTs are “serious about finding our way out of the economic crisis”.

He also expects to see greater collaboration and thinks individual PCTs will begin to specialise in some of the more technical skills, sharing expertise across regions.

This will be coming in the nick of time, as recession bites - Mr Stout acknowledges that more time to prepare for the downturn would have been “preferable”.

But he points out: “PCTs themselves are still optimistic and up for it and going for it. It’s a huge challenge but I don’t think there’s a plan B so the truth is we have to make this work.”

HSJ’s Practice Based Commissioning conference is in London on 1 July.


September to December 2009 PCTs prepare for assessments

January to March 2010 Plans are analysed

April to May 2010 Panel days take place

June to July 2010 Calibration and publication of world class commissioning results

Source: DH