1. © Nuffield Trust The future of commissioning Dr Judith Smith Director of Policy The Nuffield Trust 8 March 2013

2. © Nuffield Trust The story so far

3. © Nuffield Trust Commissioning in the reformed NHS Significant faith continues to be put in commissioning, as seen with current reforms Idea that commissioners can challenge providers and use contracts to bring about improvements Now firmly put into the hands of clinicians And this will have to work in a framework of choice and competition

4. © Nuffield Trust Is this a triumph of hope over experience? Commissioning has struggled to shift care away from hospitals towards community settings It has found it difficult to stem the rise in emergency admissions It has failed to reduce health inequalities in England Conclusion of a review of the impact of commissioning under New Labour (Smith and Curry, in Mays et al, 2011) : ‘When weighed against the transaction costs of running a commissioning system, the verdict would seem to be weak or at best equivocal.’

5. © Nuffield Trust Verdicts on commissioning ‘Weaknesses remain, 20 years after the introduction of the purchaser-provider split. Commissioners continue to be passive, when to do their work efficiently, they must insist on quality, and challenge the inefficiencies of providers, particularly unevidenced variations in clinical practice. (Health Select Committee Inquiry 2010, p38) ‘The experience of Stafford shows an urgent need to rebalance and refocus commissioning into an exercise designed to procure fundamental and enhanced standards of services for patients, as well as to identify the nature of the service to be provided.’ (Francis Inquiry report, para 1.35)

6. © Nuffield Trust Do we know what commissioners actually do?

7. © Nuffield Trust New Nuffield Trust research for NIHR (Smith et al, 2013) Two-year (2010-2012) in-depth study of three primary care trusts and their GP commissioners, and how they commissioned care for people with long-term conditions Commissioning observed to be a very labour-intensive activity Characterised by much more relational work (e.g. Developing collaboration and consensus with providers) than harder edge ‘transactional’ work Commissioners act as the convenor of the local system Commissioning work often focused on relatively marginal service changes

8. © Nuffield Trust Effort involved in this labour of commissioning did not always seem proportionate to improvements in services Commissioners struggled to describe the outcomes they were seeking to achieve Financial matters seemed frequently peripheral to commissioning discussions Effectiveness of commissioning significantly hampered by periodic reorganisation

9. © Nuffield Trust What does this mean for the future of commissioning?

10. © Nuffield Trust 'Commissioning by Clinical Commissioning Groups will, in two years, result in higher quality, more efficient health care than commissioning by primary care trusts today'. How far do you agree with this statement?

11. © Nuffield Trust 'Commissioning by Clinical Commissioning Groups will, in two years, be more effective than primary care trusts have been in breaking down the barriers between primary and secondary care'. How far do you agree with this statement?

12. © Nuffield Trust We need to decide what we want CCGs to do Confidence is lacking re their ability to secure higher quality and more efficient services But there is optimism about their ability to bring about improvements in co-ordination of services across primary and secondary care When taken alongside the evidence of commissioners preferring relational and collaborative work, what do we want of CCGs? Should they focus on developing integrated delivery of care for long-term conditions, urgent care, children and older people?

13. © Nuffield Trust We need to decide what commissioning is to be It would seem to be time to develop new smarter arrangements that offer other ways of sharing service and financial risk with providers And if commissioning is to be really about quality as well as cost, much richer and more timely data will be needed, both quantitative and qualitative This can really play to the strength of local clinicians leading the planning and funding of care So will the CCG be a local service development and improvement organisation? And how will it do this whilst shaping a local NHS market through the use of contracts?

14. © Nuffield Trust Acknowledgement and disclaimer This project was funded by the National Institute for Health Research Health Services Delivery Research programme (project number 08/1806/264). The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR HSDR programme or the Department of Health.