World class commissioning values are a legacy for the long haul

As the consultation paper Liberating the NHS: commissioning for patients makes clear, the proposals for GP commissioning and the NHS commissioning board mark a fundamental structural break with the past.

So world class commissioning is dead. Long live world class commissioning

But among other things, the white paper itself defines NHS commissioning as “understanding the health needs of a local population or a group of patients and of individual patients; working with patients and the full range of health and care professionals involved to decide what services will best meet those needs and to design these services”.

Elsewhere the white paper talks about the ambition of achieving “world class outcomes”.

Sound familiar? Not surprisingly perhaps, this is all very similar to the vision of commissioning set out in the previous government’s world class commissioning programme. The changes proposed by the white paper are not so much about the ambition or even the tasks, but more the means of delivering commissioning.

What is different is the empowerment of GPs to lead commissioning, the national policy focus through the commissioning board, the greater emphasis on patient choice and competition, and the enhanced role of local government.

There is little doubt that the competencies set out in world class commissioning are as applicable to the replacement system as to the present one. While we should not expect individual GP commissioning consortia to be able to deliver all these competencies, the overall system will have to.

So while the phrase “world class commissioning” seems to have been abruptly dropped from the Department of Health lexicon - I suspect to the relief of many - we should not be so quick to forget what we have learned about commissioning through the world class process.

Congratulations are due

The world class commissioning assurance scores for 2009-10 have now been published by most primary care trusts, though not collectively by the DH as originally planned. Results show a marked improvement on last year and are proof of the hard work of PCT staff in driving up standards. Congratulations should be rightly offered to those who have shown such progress over the past two years since the programme’s inception.

The commissioning assurance process was originally designed as an independent assessment to help PCTs identify areas of development. It was never expected to produce top marks from year one, but aimed at steady improvements in performance year on year.

The overall effect of changes made in this year’s assessment process has been to raise the bar and make the system more challenging. This means the improvements achieved are all the more significant.

The PCT Network’s analysis of 146 of the 152 PCTs’ competency scores on a national level shows an average improvement of nearly 40 per cent for the 10 competencies assessed in both years of the programme. Some PCTs were starting to demonstrate genuinely excellent performance in a number of elements of the commissioning process, although no PCT has yet demonstrated this in every element of commissioning.

Almost all PCTs have made strides in several areas, including strategic planning, financial control, engagement with local communities and procurement and contracting skills.

The competencies on which PCTs were judged showed they continue to score best on engaging with community partners and locally leading the NHS. They also showed PCTs’ most marked improvement over the last year was in stimulating the market, the area in which PCTs did worst in the previous year. An extra competency - ensuring efficiency and effectiveness of spending - was added in year two. PCTs did least well on this, suggesting definite room for improvement in an area of great importance given the quality, innovation, productivity and prevention drive.

The world class commissioning programme also analysed governance standards, with PCTs assessed on three elements of governance - strategy, finance and board. The tests on strategy in particular were tougher in year two. PCT performance on governance improved overall between year one and two. In particular the assessment of PCT boards showed a significant improvement, with 62 per cent of boards rated green, up from 47 per cent in year one. Finance ratings improved least, with a marginal increase in the number of green rated PCTs.

Rather like the Monitor tests for foundation trusts, this can all sound very technical - what really matters is what difference it makes to the health of local people.

Financial restraint

PCTs have remained committed to high quality NHS services at a time of increasing financial restraint, engaging with local communities and staff to consider the best ways of providing care and consulting with relevant parties about difficult decisions on the continuation of certain services.

The individual PCT world class commissioning reports also feed back about progress on outcomes in local priority areas. Encouragingly these generally show that the improvement in the competence and governance of PCTs is starting to lead to improvements in outcomes. If you don’t believe it, read the report for your local PCT.

So what can we learn from these results and the overall world class commissioning process as we start to design the new system of commissioning set out in the white paper?

First, PCTs have made good progress in improving the quality and effectiveness of commissioning. While this progress is not uniform and there is still room for improvement in many areas, it is vital that we do not lose the skills and capacity PCTs have built up in the transition to the new system. Much care needs to be taken to safeguard these abilities and experiences.

Second, the white paper proposes that the NHS commissioning board will be responsible for authorising GP consortia when it is satisfied they have the capacity to fulfil their statutory duties and accountabilities, and for developing an assurance process. While a full-blown assurance regime in the style of world class commissioning would be inappropriate, there are some lessons we can draw from what has gone before.

Some elements worked well - the co-production approach, clarity about what is included in the assurance process and how judgements will be made, stepping stones to excellence, two-way conversations about performance and development. Other elements would need to be done differently - less data collection, and greater focus on outcomes rather than process while ensuring there is the information to back that up and make it possible.

The end of the world class commissioning programme should not signify an end to the scrutiny of what quality commissioning should look like when GPs start to take the reins next year. Instead it will be a foundation for what will be expected of GP consortia.

So world class commissioning is dead. Long live world class commissioning.