Commissioning: skills for the future

Public service professionals have been trusted in their performance ever since the notion of state healthcare and the Beveridge report of 1942, which introduced social security benefits and a minimum standard of living.

It has been assumed that those working in the public sector give the best possible performance from scarce funds, and before 1997, nowhere did this sentiment run more deeply than the NHS. You only have to look at the GP patient survey, conducted at the start of the year and released in the summer, to see that once again primary care access ratings still run close to 90 per cent. However, performance statistics in other areas of the health service suggest this concordat does have some issues.

The deal between a government and autonomous professionals practising medicine exists with varying degrees of independence. Within this range lies the purpose of commissioning. Some, such as social policy expert Rudolf Klein, argue professionals have only tolerated budgetary constraint in return for clinical autonomy.

Cementing foundations

All of this is set to change. The Cabinet Office review of public services published in March, Building on Progress: public services, highlights the importance of recognising the needs of the public as consumers. If you accept some truth in all of these arguments it is easy to see that primary care trust commissioning represents the best opportunity in the Western world to cement the foundations of the NHS forever.

Simply put, assessing clinical need, arranging contracts to reflect demand, managing performance against clinical evidence and reflecting consumer satisfaction should be the four cornerstones of NHS commissioning.

What does this mean for practice-based commissioners working in primary care? The answer is certainly not directive as guidance has only emerged slowly since the first 20 pages of aspiration published in December 2004. Critics aside, the one thing I have seen across the country is the power of grass roots solutions. There are no national prescriptions, analytical systems or centralised contracts governing PBC or PCT commissioning. Diversity will certainly allow the best to shine but could create larger distortions than any previous postcode variation.

My colleague at UnitedHealth Europe and HSJ columnist, Simon Stevens, often spars with me, saying that if you assume only 50 per cent of GPs are interested in PBC and an independent set of 50 per cent are capable, statistical variation would imply that only 25 per cent of practice-based commissioners are likely to be both interested and capable. It might be worth reflecting on the characteristics that may develop the concept of elusive clinical leaders.

Not surprisingly, the first attribute has to be interest. The most successful projects have emerged with motivated, meritorious people holding the belief in a better way for their patients. After all, with the recent contractual pay raises the enhanced service payments are worth precious little so early pioneers have clearly dispelled some of the myths of financial motivation.

Second has to be the ability to manage time. Commissioning meetings, service reconfiguration and writing plans consume huge amounts of time. The problem for most will surely be the conflict between patient time and time spent on commissioning projects. For every leader who suggests that good management leads to better care there will be one who believes that if we all saw more patients and had more money this would all be a lot less hassle.

Third comes vision: the most productive chief executives and clusters have one thing in common - a view on how things should look in three years’ time. Whether you agree or not, setting a strategy for any organisation, with steps, goals and milestones, will achieve far more than individual feats.

With vision comes leadership - setting parameters within which colleagues can agree will produce not only incremental change but also potentially logarithmic growth. My cluster of practices had a varied year against a plan but, despite all the mishaps I firmly believe that monitoring progress with disseminated information influenced colleagues. This achieved far more than the sum of the rest of our initiatives. The resulting cool half million represents close on 2 per cent of budget (to be debated and split with the PCT).

This leads me to my two final points. Data information systems and analytics will be the biggest growth area in the next five years, so if you employ a great data analyst go and give them a hug and a pay rise before someone else does. My third plank of commissioning performance can only ever be resolved with data, tracking budgets and measuring variation. On a political note, if the NHS had invested in an information strategy rather than a national IT programme we would be much further ahead, again with local innovation.

Power lunch

Finally I come relationships. I have seen many styles and was unfortunately introduced to trench warfare when my patients’ elderly rehabilitation ward was closed without consultation. Trading press releases was all very amusing and I even had my previous acute trust and PCT chief executive cowering behind their chairs when BBC One’s Panorama came for a little chat. Undoubtedly, and I am sure with a little maturity on my part, the best progress has come with regular forums, open lines of communication and the greatest British weapon of all, lunch.

The bad news is that absolutely none of this is taught at medical school or during postgraduate jobs, and only appears in tantalising micro-portions in membership exams if you dare tear yourself away from the party line of communication skills and educational theory.

Fortunately, there are many enlightened organisations with ideas, seminars and assistance. The Improvement Foundation is keen to introduce the willing into PDSA (plan-do-study-act) cycles and the art of self-assessed performance. The National Association of Primary Care arranges good-value seminars and support. The NHS Alliance offers an information-rich website if you can log on, and a variety of media outlets, including the Department of Health, arrange seminars with leaders.

The greatest untapped gems have to be the NHS Institute for Innovation and Improvement, and the Information Centre for health and social care. Start by visiting their websites.

My conclusion after a whirlwind tour of commissioning: nothing beats getting on with it. Commissioning has to be the only policy that allows those interested in markets or in socialised healthcare to work closely together.