Helping the NHS keep its promises – Could CCGs simply buy new types of care?

As I observed a couple of weeks ago (and it still seems a little odd), the 2017 Conservative Manifesto[1] did promise to get rid of the purchaser/provider split (where it gets in the way of patient care). Given that I can’t see Jeremy Corbyn’s Labour Party going to the wall to keep commissioning in public services, it would appear that politically there isn’t much sign of the task of purchasing NHS care appearing over the horizon.

However, whilst its future may be uncertain, it is still a major part of the current structure of the NHS. Indeed, the legal name of NHS England is the NHS Commissioning Board, so you would expect that commissioning would be a implementation cornerstone for the NHS to implement its new promises to the English people.

There are a significant number of people in the NHS whose job title contains the word ‘commissioning’. It seems reasonable therefore to look at the possibility of NHSE using its own staff and their commissioning tasks as a method of delivering new forms of care.

After all it was Simon Stevens, the CEO of NHSE, (a commissioning organisation), that arm-wrestled the Treasury into delivering the extra money. Nominally at least NHSE is being given £20 billion of extra money by the government to go and buy us some extra health care. Isn’t it simple? If, for example, we want all diagnostic tests for cancer to be carried out by Artificial Intelligence by 2020, why don’t commissioners simply commission it to be delivered?

The purchaser/provider split in the NHS is now decades old, but after going through many iterations few people think that it really ‘works’ to achieve what it should be achieving. I remember, back in 2001-2005 when I was working with new Labour Secretaries of State, regularly visiting the chairs of Primary Care Trusts (PCTs) to work out how they could commission different care. This was never straightforward. Even if they wanted to buy different forms of care major local NHS providers always had public support in resisting any changes that commissioners wanted. If people had to choose between what their local hospital wanted and what a set of bureaucrats called commissioners wanted they usually came down on the side of the hospital.

Looking back on my work between 2010 – 13, I gave a series of talks to health care systems about developing outcome-based contracts. The hope was that commissioners would move away from contracting for care inputs to work with providers and the public to commission outcome-based care. This involved moving away from paying for inputs (an activity that a provider does for a patient or service user).

Input categories make sense to providers. A hip replacement, for example, is a part of their organisational activity. So by commissioning inputs CCGs were working with the grain of how providers were organised, and not what patients needed.

If CCGs were to commission outputs it would still involve the results of the input for the patient. For our example of a hip replacement this would mean buying an output for the patient to have the hip replacement – and be successfully discharged.

An outcome is very different. It is something that the patient receiving the input wants as a part of their life. This could be a desire to walk to the shops after a month with their new hip or to be able to travel to visit a relative.

Outcomes are much more difficult for providers to organise as they involve issues that are controlled by the patient and not the provider. Providers can only achieve outcomes if they are fully engaged with the patient. Achieving outcomes will depend upon the public being very actively involved. Outcomes must involve them and their lives.

I remember, 6 or 7 years ago, a number of discussions with CCGs and older people’s groups, about the outcomes older people wanted from health services. These could be broadly summed up as “maintaining independence”. But what became clear at the time was that, if NHS providers were only paid for those services that maintained independence, they would have real problems as much of what the NHS does creates dependence. Would providers still be paid if the outcome they were meant to be providing was independence?

This was the right thing to think about but very, very hard for providers to do.

So let’s be honest, of the billions of pounds that pass through commissioners hands very, very little of it buys outcomes. Nearly everything commissioners buy are inputs and most of them are the ones providers would provide anyway – without any input from commissioners.

We can therefore conclude that those parts of commissioning that involve buying care do not have a great track record of bringing about change. So it’s not likely that the buying of care will create the relationship needed to bring sufficient change in the NHS to meet its new 2018 promises.

However, there are other activities that CCGs engage with that can bring about change and we will look at these tomorrow.

[1] If the current legislative landscape is either slowing implementation or preventing clear national or local accountability, we will consult and make the necessary legislative changes. This includes the NHS’s own internal market, which can fail to act in the interests of patients and create costly bureaucracy. So we will review the operation of the internal market and in time for the start of the 2018 financial year, we will make non –legislative changes to remove barriers to the integration of care. Page 67 Conservative Manifesto 2017