HSJ gathered some of the biggest names in primary care to discuss the Department of Health’s ambitious world class commissioning programme as part of a live, online debate. Andy Cowper listened in
Gary Belfield opened HSJ’s online debate on world class commissioning by explaining just what the programme means to normal people. The Department of Health’s director of commissioning used some mind-boggling numbers to illustrate the scale of health inequalities in England.
“Primary care trusts spend £70bn of taxpayers’ money a year - £200m a day - to prioritise long term health gain,” he told the online debate. So world class commissioning is the NHS’s chance to address the country’s huge health inequalities through the NHS budget, itself “bigger than the economy of Egypt”. Choosing the issue of infant mortality to indicate inequalities, he noted that while nationally five babies per thousand born die in their first year, this figure rises to 16 babies per thousand in a deprived area such as Pendle. The focus, Mr Belfield suggested, must be on health outcomes and long term health gain.
Transformation was the outstanding concept of the programme for Birmingham East and North primary care trust chief operating officer Andrew Donald - “working through what commissioning is and how we do it”. He insisted primary care trusts should be moving beyond their focus on the acute sector to take on “preventive healthcare and social responsibility”. This would mean working with other agencies to deliver preventive services more systematically.
World class commissioning, he said, will mean “doing the ordinary extraordinarily well”.
UnitedHealth chief executive officer and HSJ columnist Simon Stevens found nothing to argue with there. But world class commissioning has a long way to go before it spans the whole NHS, he said. And he warned against the risk of too much focus on “the flows of healthcare transactions and not enough focus on the stock of population health risk. We need patient and population perspectives as well as transactional ones: world class commissioning is about both.”
Mr Stevens suggested the big work will be putting the 11 national world class commissioning competencies into three main areas: planning (health needs, matching resources and transformation); market making and procurement to drive change; and relationship equity and mobilising consent for service changes.
With clinical engagement a central feature of Lord Darzi’s next stage review, the group - chaired by Jeremy Nettle, healthcare director of the webinar’s sponsor, Oracle - spotlighted leadership issues and secondary care clinicians’ roles in commissioning.
Mr Donald saw clinicians’ involvement as fundamental: “We have to work with providers to develop model services.”
Mr Belfield reiterated the policy statement that “great clinical leadership is at the heart of world class commissioning”. The DH has launched a PCT clinical leadership group and pilots for integrated care systems are under way. Mr Stevens asserted that this must mean services, not organisations, being integrated.
Those watching the discussion online fed it with a steady flow of questions. The first asked whether single unitary councils would impact on the NHS’s ability to implement world class commissioning effectively. All participants agreed the overlap between health and local government in commissioning would be important.
In Mr Donald’s words: “We are looking at community issues with local authorities on how to deliver transformational change. This means we need to offer things up to local authorities so they see benefits in working with the NHS.”
Mr Belfield said he had seen “a sea change in the last six months, with PCTs really getting it, with lots of joint working examples like Tower Hamlets PCT showing almost seamless connection between PCT and local council”.
Mr Stevens again raised the need for a radical shift, “a commissioning system of horses for courses”, as he put it. “In some areas, GP commissioners can take on a big chunk of responsibility while in others GPs are either not up to it or not interested, so commissioning is a PCT role. In others, local authorities could be interested in the chance to influence commissioning of NHS services. We need a mixed set of models.”
Mr Belfield outlined the DH team’s general view that commissioning skills should be developed locally, “not driven by a DH masterplan”.
He called for a national framework to improve skills for all PCTs.
“We think it is exciting that PCTs are driving their own development and starting to work together in skills transfer,” he said. “Actuarial and health economic skills are rare, so it’s not rational to have one expert per PCT in each [skill]. Instead people share them across a patch, recognising that they can’t do it all on their own.”
A viewer then took the team up on the whole question of how to disseminate best practice across a federated organisation like the NHS. Mr Donald said PCTs needed a “best in class” mindset, so they could understand development needs and what the market can provide.
“Working with private sector support since 2005, we have gained vital skills and expertise in the way we contract, project manage, transform and measure outcomes,” he said.
Mr Stevens said excitement must come back into commissioning. “For too many, commissioning has seemed like another wretched plan that needs staff to get their heads down to get it out for October. It is the old arm-wrestle with the acute trust over coding and billing. There’s not been enough measurable change. We know not enough areas have specialist stroke admission units but we know these make improvements to population health. So how do we use our commissioning to deliver that?” he asked.
An audience question about tools and techniques for world class commissioning then prompted Mr Stevens to reflect on the importance of near real-time data and programme budgets.
“PCTs are trying to drive using the rear view mirror. Their last figures were for 2006-07. At UnitedHealth our programme budgets run per member [of an insurance plan] on a weekly or monthly cost basis. So we can identify, by provider and by disease groups, patient sub-groups that are consuming more avoidable healthcare than we would expect.”
Mr Donald said his PCT has real-time feeds of data from local accident and emergency departments to their GPs.
“If we understand service use, we can target change. We recently found data on a patient who had been admitted through accident and emergency with alcohol and mental health problems 39 times in one year.” Commissioning was about asking, “where are the services to prevent those 39 admissions?” he said.
Mr Stevens noted estimates that there are£1bn worth of avoidable hospital admissions a year and cautioned that the annual commissioning cycle will not reach those figures.
“We need to get into the ‘black box’ of community services to prevent avoidable admissions,” he said.
Mr Belfield stressed the need for information and data to inform decisions and for a strong PCT board grip on local issues, saying: “Becoming world class is all about local delivery.”
Mr Stevens then put forward the idea that public engagement should be seen in a three-way public health context: “One, become more consumer literate, linking health data with other socioeconomic data sets that show which groups respond to which approaches; two, have emotionally intelligent public health; and three, develop economically savvy public health approaches, including economic incentives.”
Mr Donald agreed, adding that a world class commissioning strategy could be to offer council tax rebates for participation in healthy activities.
“It’s about being imaginative, having conversations and discussions, getting out into residents’ spaces and understanding what they’re saying. You need to understand their lives, their needs and what they want.”
With the discussion moving on to whether real-time data will become available on individual client groups, Mr Donald pointed out that the NHS already has a lot of information available.
“The questions are, is it really useful and can we get at it? Knowledge management is the real competency challenge for us as for most PCTs and that’s where we’re focusing a lot of our capacity-building.”
Another questioner asked how practice based commissioning will co-operate with the public health agenda, when one world class commissioning competency is to stimulate the market.
Mr Belfield admitted the DH’s story on practice based commissioning “is not as clear as it should have been. Later this month, we will be working with 70 clinicians to set the story straight on how it will fit in, which it does. For market innovation and stimulation we need PCTs to be really clear on health outcome data and then to challenge local providers on how to deliver those outcomes.”
Mr Stevens pointed out that such levers will make some PCTs uncomfortable.
But Mr Donald suggested PCT commissioners “need to be brave in giving up sovereignty to practice based commissioners [in order] to let them get on with it.”
A questioner asked why, when GPs commit the majority of NHS resources, are budgets, data and management resources provided for the initiative so often described as inadequate.
“Probably because they are,” responded Mr Stevens. “GP commissioners should have much more latitude to describe what they want. In general, I think the commissioning process is under-resourced.”
He added: “The flip-side of devolved commissioning to GPs is that PCTs must pay more attention to the commissioning of GP services if they are to be serious about addressing health inequalities.”
While Mr Donald concurred, Mr Belfield was more optimistic, noting a third of practices now report to the DH that they are getting useful indicative budgetary information. Stockport PCT had delegated 90 per cent of its budget down to its practice based commissioners, he reported, while Hampshire PCT, the country’s largest, had delegated its management budget.
Transformation not complication
Discussion turned to the subject of demystifying the complexities of commissioning. For Mr Donald, “avoidance of jargon is the key”.
“It’s human nature to overcomplicate things. This isn’t just about performance management, it’s about transformation,” added Mr Belfield. “If we don’t get this right there is a real risk of defaulting back to traditional NHS command and control. Changing the whole way of working takes time. We need to give commissioning some time and not beat ourselves up in the meantime.”
Mr Stevens observed that the current national iteration of assessing NHS commissioning capability is the third he has seen in his career, “the change being that this iteration is being done with much more rigour and a good balance between facing facts and honesty about improvement needed”.
Asked by a PCT audience member for help with their board review, Mr Donald suggested development should be done as a board - executives and non-executive directors together.
Mr Belfield offered: “Don’t cram like you’re trying to pass a test. This is about long term health gain. Focus on your population and plan where you’re going next.”
“The most important thing is to think about how this fits with stuff you have to do as an organisation anyway,” added Mr Stevens.
And when asked by a viewer how a lead commissioner could measure their personal success, Mr Donald suggested the measure should be “your population becoming a little healthier - people saying that they feel better for and appreciate the services you commission”.
Mr Stevens was keen on the mirror test. “Can I look at myself in the mirror once a year and answer the question ‘is care better’? And develop measures to integrate health and social care.”
Responding next to a question about PCTs under-reporting their abilities in the world class commissioning assessment so as to show progress next year, Mr Belfield warned: “We have tested it with five PCTs. They and we think the process is robust but fair. PCTs should be hard on themselves, but don’t try gaming. You will be found out.”
Mr Donald agreed, suggesting that mismatches between the 360 degree review, organisation self-analysis and analysis of their evidence documents would reveal any gaps.
Wrapping up the event (which overran due to the number of questions received), Mr Donald observed: “The real challenge is making sure that all the connections get made at local level. This is about local services working together in a co-ordinated way. Be realistic on what you can achieve, but be brave. Take risks and go and talk to people who can deliver what you need to become world class.”
Mr Stevens concluded by saying he believed professionalising commissioning will change what it means to be an NHS manager: “The old way of zipping from jobs in acute trusts and mental health trusts to being a PCT commissioning director will fade out, replaced by more sub-specialisation in technical areas,” he said.
“Keep perspective and take pride in achievements but also juxtapose it with some outrage. Some services are still not good enough. Don’t just shrug your shoulders - use your commissioning to do something about it.”
And finally Gary Belfield’s advice: “This is really tough. It’s meant to be. This is a long haul, two to four-year process. PCTs need to step back and think like that.
“Good luck - we know it’s difficult.”
Jeremy Nettle, chair, director of healthcare, Oracle, the event’s sponsor
Gary Belfield director of commissioning, Department of Health
Andrew Donald, chief operating officer, Birmingham East and North PCT
Simon Stevens, chief executive officer, UnitedHealth, and HSJ columnist
World class competencies
Locally lead the NHS
Work with community partners
Engage with patients and the public
Collaborate with clinicians
Manage knowledge and asset needs
Stimulate the market
Prioritise improvement and innovation
Secure procurement skills
Manage the local health system
Make sound financial investments