Wednesday, April 22, 2009

A New Way of NHS Commissioning

On 22nd April I was invited to attend an event in Manchester, jointly organised by NHS North West (the North West region's Strategic Health Authority) and Voluntary Sector North West (VSNW).

The packed audience at one of Manchester City Stadium's conference suites was made up largely of Voluntary (so-called "Third Sector") organisations, who were there to learn about what a change in NHS organisation could mean as an opportunity for them. Over 100 delegates attended.

Transforming Community Services

The Transforming Community Services programme is the latest in a series of fundamental changes to the way that health and social care is conceived, procured and delivered in England.

The process began more than a decade ago, with the devolution of responsibility for health provision to Primary Care Trusts (PCTs), which are responsible for determining how best to serve the needs of their area.

Simply put, PCTs are allocated money from Central Government through their regional Strategic Health Authorities (SHA's) to assure the health and wellbeing of the populations they serve. Crucially, however, nobody from outside tells them how to prioritise what's needed or how to address those needs (other than to meet certain quality standards).

World Class Commissioning

These shifts were also accompanied by a broader understanding of what NHS care is about. The focus has steadily moved from a medically-driven model of curing people who are sick, to a more preventative and socially informed approach, increasingly focussed on developing health and well-being – preventing people from getting ill in the first place.

This kind of change in emphasis was initially slow to take root – mainly because health service professionals who had been brought up on the old way of seeing health provision were slow to break out of the mould of letting service provision be determined by what clinicians thought they should be treating. A new approach was needed – an approach that would encourage thinking about the services that communities actually need, and delivering those services in ways that those members of the public would prefer to see.

Eighteen months ago the Department of Health launched a programme dubbed "World Class Commissioning" (WCC). The aim of WCC is to break that old style model of thinking. It is framed around a whole new set of so-called "competencies" for a new breed of NHS commissioners. Commissioners are the health service managers who are charged with determining service needs, designing how to meet them, looking for suitable providers, legally contracting them and then monitoring to ensure delivery is successful. (In the longer term they also determine whether priorities have changed, or whether different kinds of delivery approach are needed and evolve the services they design and procure to match that.

Involving Communities

A central competency in World Class Commissioning is the ability to engage with service stakeholders in order to really get to the bottom of the evidence for need, an understanding of what people want, and how they want it to be provided.

Good WCC work requires an understanding of local diversity, along with an eye for how to engineer equal outcomes from services, in order to ensure that the NHS meets the needs of everyone, and not just part of the community.

Now, in the latest part of the change process, there is also an emphasis on becoming more innovative regarding service provision.

Resolving a Conflict of Interest

Primary Care Trusts commission services, as described above. Many of those are procured from local Hospitals (Acute Trusts) or specialist services such as Community Mental Health Trusts (CMHTs) or Ambulance Trusts. General Practitioners are also contracted by PCTs.

Yet traditionally PCTs have also been the providers of some of the most important services too, such as local clinics. This then creates potential conflict of interest when it comes to monitoring those services.

Also, PCTs and Local authorities need to be able to work together at local level, especially in services where the division between health and social care is blurred. This becomes more complex when a PCT is both involved in commissioning and delivery.

The aim of TCS

On one level, the Transforming Community Services programme is about removing that conflict of interest and making possible a wider diversity of service provision in areas where PCTs would previously have dominated.

By October 2009, all PCTs are expected to have drawn up plans for how to split the commissioning and provision aspects of what they do. So, in each existing PCT patch there will be an organisation whose sole purpose is to apply the disciplines and competencies of World Class Commissioning to work with communities to design and procure services that are fit for the purposes of their local population. They are expected to develop the means to consult and include real patient stakeholders, and to be prepared to redesign the specifications of services they require on the basis of the feedback they receive.

In some cases very little might change. The kinds of medical services provided by existing local hospitals will still be needed; yet providers might be asked to change finer details of how services look and feel to the public they serve.

In other cases the change process may be far more radical as contracts come up for renewal.

Different approaches are already emerging. Some hospital trusts are already gearing to bid for providing community services to several PCTs at once. In other cases the staff who run existing local clinic services have the opportunity to perform the health service equivalent of a management buyout and bid to become an independent provider. In other areas we are bound to see some services being commissioned out to private sector providers too. Traditional private hospital operators are in a strong position to bid to replace some GP clinics or community hospitals.

Some of these changes are bound to be controversial, and there are still many unknowns. For instance, will staff in provider organisations continue to be employed under NHS terms? (A question with significant implications for pensions, for instance).

However, the aim of this article is to discuss the opportunity opened up to third sector organisations who already provide services which are important at the social care end of the health and wellbeing equation.

What TCS means for charities and social enterprises

The opening up of the market for provision of local services to PCT commissioning arms is new and hugely significant for the future capacity and sustainability of the third sector. In short, it provides the opportunity for those organisations (singly or in consortia) to bid on an equal basis to receive health service funding to provide services to the community on a long term basis.

The opportunity raises many questions on both sides of the equation. Commissioners have a great deal to learn about how to engage with third sector candidates for service provision. Equally, voluntary and community organisations have much to learn (and some challenges to overcome) in order to be in a position to bid effectively to provide top quality services in a sustainable fashion.

The event in Manchester on 22nd April was designed to introduce the opportunity and discuss the challenges. Following on from this, a series of roadshow events will be staged around the region to bring commissioners and prospective suppliers together. These will be particularly valuable for specialist services such as Rape and Domestic Violence Centres.

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