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Thoughts and opinion from the wards
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Why ask clinicians to commission?
At the heart of the current reforms is the intention to put clinicians in charge of commissioning. Why do that when the prime concern, surely, for a doctor is to do the best for the individual in front of them? That is the first rule of the GMC’s Good Medical Practice. However, as Daniel Sokol argued recently, making the care of your patient your first concern is not as simple as it seems. No patient is an island and the actions which clinicians take commit resources. Resources are finite and need to be used in a way which delivers the greatest value for money. Commissioning can be viewed as a process which should support professionals in managing the ethical conflict between doing the best for an individual whilst discharging a responsibility for a population.
Ask people to define commissioning and you will get a variety of responses. This reflects the complexity of the job. At its simplest it is about understanding health needs, involving people and professionals in planning services to meet those needs and then procuring and performance managing the commissioned services. But, in reality, it is far more than that. It is about politics, perceptions, leadership and, critically, it is about changing clinical behaviour. Chris Ham has described the NHS as having an ‘inverted pyramid of power’, where the real decision making is made by professionals working with patients every day. Unless those with the power endorse and support the system that has been commissioned for them to work within, then it is doomed to fail. Which is, perhaps, the rationale for putting clinicians in charge of commissioning? So is there evidence that having clinicians committed to commissioning is a good idea? Probably. The trouble is, whilst providers have remained relatively stable, commissioning structures have been subjected to such frequent reforms that by the time they are becoming established they are then disestablished. This has made evaluating the effectiveness of commissioning in the NHS difficult. Why GPs? Given the factors outlined above there is an argument for involving General Practitioners in commissioning. They see the majority of the population on a regular basis. They see the processes and outcomes which their patients experience separate from the rest of the system. The nature of healthcare is changing, with long term conditions and frailty dominating the consumption of NHS resources; issues which require working with social services, the third sector and public health. Importantly, what is becoming more and more relevant is that how resources are organised within General Practice has an impact on how resources are committed across the rest of the system. Variation in practice has a significant impact on the effective use of resources. Bringing GP practices together to focus on transforming primary care is intended to drive improvements in quality right through the healthcare system. It simultaneously creates influence and accountability for a part of the system which, in commissioning, has lacked both. What about other professionals and the public? Commissioning is multilayered and to think that GP consortia will have unfettered influence is nonsense. It might be postulated that the prime function of GP led commissioning is to co-ordinate and properly harness the potential of primary and community care and support greater collaboration across the system. At a strategic level the National Commissioning Board will oversee the creation of a national commissioning framework and standards and will hold GP consortia to account. The tokenistic appointment of professionals to the boards of organisations is no guarantee of improving the way commissioning is done. Specialists already have enormous influence on commissioning. The Royal Colleges’ standards and NICE guidance are just two examples of how commissioning is driven by specialist insight e.g. the “improving outcomes” guidance transformed cancer commissioning. Although GPs might be given considerable influence over commissioning they will be unable to navigate its complexity unless they properly involve and engage, not only other professionals, where appropriate, but also the public they serve. Why should clinicians commit to commissioning? In a recent book Porter and Teisberg articulate the case for focussing on value for money. Put simply their proposition is that value for money is determined by quality and cost. The recent Next Stage Review defined three components to quality: safety, effectiveness and patient experience. Commissioning can be seen as being simply about managing the money which will not inspire the majority of clinicians. The best commissioning must be about increasing value for money. Creating a safe system which is as effective as possible and which delivers a good experience for patients is something to which clinicians aspire. The reforms infer that clinicians committing to commissioning will be the best way to make that happen.
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