Commissioning Healthcare in England: Evidence, Policy and Practice

The aim of this book is to bring together in one volume the most important research which the Policy Research Unit in Commissioning and the Healthcare System (PRUComm) has undertaken during the period 2011 to 2018. PRUComm is a multicentre research unit based at the London School of Hygiene & Tropical Medicine, the University of Manchester and the University of Kent. PRUComm is funded by the Policy Research Programme of the English Department of Health and Social Care from 2011 onwards to provide evidence to the DHSC to inform the development of policy on commissioning and the healthcare system. The analytical work supports understanding of how NHS commissioning operates and how it can improve services and access, increase effectiveness and respond better to patient and population needs.

The structural changes introduced by the Health and Social Care Act 2012 pursuant to the twin policies of increasing clinical involvement in commissioning and accelerating market forces have had large effects on the practice of commissioning across the NHS.

There has been a great increase in the complexity of health system governance. The number of bodies undertaking commissioning has increased and there has also been a proliferation of other NHS organisations required to regulate the complex system. The effect of this increase in complexity in the governance of the NHS has been wide-ranging. As a result, local

autonomy is severely limited and the original policy aspirations to deliver freedom from government control and greater accountability to patients and greater democratic legitimacy have not been realised to any significant degree.

In addition, the fragmentation of commissioning roles has been damaging to the planning and delivery of services which are subject to several commissioning regimes. Not only is there evidence of deterioration in patient outcomes, but the research has also demonstrated that significant effort, and thus opportunity cost, is required from commissioners to ‘knit back together’ pre-existing systems of service planning and delivery.

The issue of accountability of commissioners is closely related to the problem of increased complexity of commissioning and system governance. Local Clinical Commissioning Groups are stated to be membership organisations whose primary accountability is internally to their GP members. But in fact the strongest form of accountability would seem to be their hierarchical upwards accountability to NHS England, the national body running the NHS. In addition, the delegation of responsibility for commissioning of primary care to CCGs presents a risk that groups of GPs will commission themselves to provide services, creating a structural conflict of interest, which may undermine their public stewardship role in respect of commissioning budgets.

The complex regulatory structures of the NHS required to police the marketised system introduced by the HSCA 2012 have effects on the efficiency of the system as a whole. Inappropriate use of market institutional structures, as opposed to integrated hierarchies, can decrease overall efficiency by increasing costs of undertaking transactions.

A further effect of the changes to commissioning introduced by the HSCA 2012 has been on clinicians in primary care. Despite the fact that the research has indicated that they can make a useful contribution to commissioning by CCGs, the workload associated with such involvement is substantial, with a potentially damaging effect on the working lives of GPs, who are already under stress from excessive demands on their time. This makes the sustainability of the model of GP involvement in CCGs dubious.

Despite the problems associated with the HSCA 2012, we argue that there will always be a role for planning, and thus a degree of commissioning in the NHS, as a publicly funded system. Strategic decisions need to be made about the allocation of public resources between different services in order to optimise population health and wellbeing. It is also necessary to monitor the performance of providers of care and make improvements where care is substandard. Thus, the core activities of commissioning are necessary whether pro-competitive quasi-market aspects of the English NHS are retained or not. But commissioning in its current form is unlikely to continue, given plans being developed at national level merge CCGs and introduce intermediate tiers of supervision.