Sophia Christie on becoming a world class commissioner

Foundation status was made available once organisations were already demonstrating strong performance on core standards. Their challenge was to demonstrate a clear strategy for delivering sustainable services which would provide a good financial return over time. Most foundation trusts have performed well at this, showing enviable surpluses.

If PCTs were now challenged to go through the same process, we would face a tricky task. Outside London, it is less than two years since we were told our investment negotiations were as nought, as the continuing gap in NHS finances was unacceptable. We rose to the challenge, delivering a£586m surplus while improving health and delivering ever faster access to ever more services ever closer to home.

So we have not been asked to match the challenge of the acute trusts. We have been asked to match the performance of world best commissioning organisations. A challenge so challenging that when Chris Ham of Birmingham University went to look, he couldn't find an organisation that was delivering all 11 competencies at a "world class" standard.

Many snide remarks have been made at the notion of PCTs being world class, but the PCT leaders who designed the approach were keen that we should aspire to the best, rather than the mean. We are after all collectively responsible for spending 8 per cent of GDP.

Rigorous process

The process is proving rigorous. PCTs have had to develop five-year strategic plans, an organisational development plan, a financial strategy and a communications strategy in addition to submitting eight other pieces of documentary evidence. Our metrics are pored over by assessment panels, led by the local strategic health authority, but made up of peer experts.

Once these panel assessments have been calibrated, we shall have feedback on three to five areas for improvement in developing and delivering our local strategy. To date then, the focus has been on what we say we are going to do. The process has given impetus to articulating vision, clarifying expectations and setting out an explicit change agenda for each health economy.

The real challenge, however, is to demonstrate the progress of this strategy in practice. The reality check here is that past performance is the best predictor of future performance and that transformation takes focus, energy, calculated risk and time to deliver. In describing our organisation's strategy, we drew on learning from the last seven years, which was salutary in the context of proposed annual scrutiny on progress.

When working across the whole system, it is essential to adopt a formal programme approach, with clearly defined work streams, multi-agency groups and accountable officers with delegated authority to act. Public health interventions require particularly strong management.

New tactics

Doing more of the same will produce the same results; instead we have learnt to be more circumspect about the health beliefs and preferences of our customers. My PCT's heart failure programme initially invited people to participate with a traditional letter; they didn't participate. Focus group work revealed we needed a non GP-based programme that could be booked over the phone; this worked.

We now invest more time upfront understanding each audience, in order to invite them into services in a helpful and attractive way.

To reach those people who have historically avoided us, or not done well in routine care, new styles of service are also needed. We are considering which other traditional face to face interventions may more effectively and efficiently be offered over the phone while exploring how to apply digital technology in our daily work and in particular in direct communication with our public.

It is exciting and rewarding to engage in innovation, partnership and improvement and easy to miss the contribution made by getting the basics right. World class commissioning places appropriate emphasis on key transactional activities. We have needed to build our capacity and commitment to process capture and management in order to design prototypes, then scale up and ensure the sustainability of services over time, particularly as they are rolled out universally into mainstream practice.

Making it easy

To do so, make it easy to do the right thing. It is easy to design bespoke systems that require additional effort and thought on the part of busy frontline staff and are therefore doomed to failure. We need instead to pay more attention to ensuring that as new interventions are introduced, they are integrated with existing practice, maximising the chances of large scale adoption. Try to avoid seduction by the artisan approach dependent on one dedicated clinician. To have an impact for a patient population of 20,000, services need to be designed to be delivered on an industrial scale.

Make the most of creative stealing. There seems little point in reinventing the wheel. If there is a service or intervention that has already demonstrated "proof of concept", ensure it is adapted and adopted as quickly and consistently as possible.

Most significantly, remember that the full cycle of commissioning, from identified need, through target group, prototyping, gateway development and impact assessment to full roll-out, takes at least two years. Specification development, with flexibility to respond to learning as services bed in, takes time, and formal procurement rules will add three months, even when managed to their tightest legal timescale. The process of adding "life to years" may yet take a few years off the lives of many of us.