As a title, Intelligent Commissioning may meet with some cynicism. This is possibly because when it comes to the practical realities, the information and guidance can appear confusing, over-complicated and conflicting.
Until recently, PCTs were the only source of commissioning wisdom with any kind of track record. But with changes to PCTs and the advent of commissioning support services (CSS), the PCTs' repository of knowledge and experience has become significantly diluted by the loss and displacement of their teams. The remaining individuals do not always add up to the combined knowledge and aptitude of those established teams.
Restructuring the NHS
It is also true that PCTs' credibility to commission has taken a knock as it has become expedient to reinforce the argument for restructuring the NHS and so justify the reasons for introducing a more diverse market of commissioning support from outside the NHS.
I can hopefully signpost some aspects that might be worth considering as clinical commissioning groups (CCGs) find their feet.
It makes sense to understand the two imperatives for commissioning competence. The first is the bureaucratic requirement for a CCG to operate. This is called authorisation. The second is the more localised requirement to deliver real improvement in service.
A key element is having the right expertise and skills. If the term 'intelligent commissioner' has any currency it is in being an intelligent customer of the various services that are now on offer whether from the residual PCT offer (now packaged into the new breed of NHS CSS) or from the growing number of private sector businesses that offer CSS.
|Future of CCG services|
|What might CCGs retain
To be an intelligent customer it is important to understand which essential commissioning functions are needed and to be able to describe these in a way that puts the CCG in the driving seat.
Most CCGs will not be large enough to justify becoming a mini version of the PCT that formerly covered the patch. Even if they were, it would make little sense to reproduce historic infrastructure.
To get the best value and to really do commissioning differently, there should be an evaluation and agreement within the CCG on which functions to build, which functions to share with other CCGs and which functions to buy in.
An outstanding benefit of in-house functions is having control and this often translates into getting things done responsively and quickly.
A shared service can feel as though it is answerable to nobody unless there are clear agreements on use. Conversely, an in-house function is a fixed cost that can be inflexible to changing needs and may not have the critical mass to do the job well. But if commissioning is to be done differently, large teams might not be the answer.
Retaining services also does not stop you from collaborating with other consortia, such as on clinical pathway redesign with secondary care clinicians.
What about contracting out for CSS? This does hold attractions in that the CCG becomes the customer. It can also offer the benefit of critical mass and economies of scale without needing to share with a CCG that has different priorities.
Outsourcing should also achieve control but this will be dependent on striking the right relationships.
There are also steps to consider when changing from the existing arrangements to the outsourced choice. This entails a procurement and human resource input and clear legal and contractual agreements. Plus, it does not stop when the contract has been negotiated. There must be regular monitoring and review to ensure that what you buy meets your needs and is value for money.
The legacy arrangements for commissioning support overseen by the cluster PCTs should be assessed to see whether they can truly deliver the responsive and effective customer service that may be available elsewhere in the market. The legacy CSS arrangements do have the benefit of being in the NHS family although 'customer service' may not be well developed. This in turn may mean that legacy NHS CSS arrangements could be influenced more by NHS Commissioning Board requirements than by their CCG customers.
Intelligent commissioning is about the decisions that CCGs make. However, those decisions will inevitably be shaped by the competence of the commissioning machinery deployed.
Each CCG should ask itself: what are my drivers for buying services? What are the benefits of staying in the NHS family? Will customers be on an equal footing? Will the change and disruption of buying flexibility make us a better CCG?
If the answer to the last two is 'yes', the choice and opportunities offered by this new market of commissioning support may well be justified.
- Dr Riley is chairman of Wellstate Commercial, which develops procurement policies. He is former chief executive of NHS Tameside and Glossop in Greater Manchester and he established the first NHS commissioning business service, which has gone on to be a model that now informs the NHS reforms for commissioning support to GP consortia.