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Keeping the flame burning


23 April 2015

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In a time when primary care is going through great changes, it is important to keep on top of things that will make a difference to local population health

In a time when primary care is going through great changes, it is important to keep on top of things that will make a difference to local population health

The challenges facing the NHS, and health systems worldwide, are well known. Commissioners know that the status quo is not tenable if the system is to deliver better care, improved population health and greater value for the taxpayer. So, instead of repeating these challenges this article focuses on implementing sustainable improvements that can start today. We see outstanding examples of commissioners really trying to grasp this challenge every day but the energy applied and actions taken are still not universal. This article – or manifesto – sets out the six actions that commissioners can all take to make a real difference to local population health. We know that commissioners working with health and well being boards, local authorities and supported by commissioning support units (CSUs) can build on their current success to go even further to improve local health.

1. Population segmentation
Successful organisations understand their customer base and where they need to have greater focus. Commissioners are no different. We have seen great commissioners who will break down their population to understand the disease profile and allow greater focus on the areas of highest need. This could mean segmenting the population by a care group for example. The days of saying that a clinical commissioning group (CCG) is spending £Xm on an acute provider needs to come to a rapid close. Instead commissioners are focusing on programme budgets of spend that embraces the acute but also brings the community spend into sharp relief as well. By segmenting the population you can then have the more detailed conversation about expectations on outcomes and where the future commissioning pound would best be invested for care or health improvement.


This is simple to do but complex to follow through as it involves making conscious decisions to reduce – or maintain a steady state – investment in some areas to allow more focus on higher priority areas.

2. Commission for multi-year improvement
We know that health improvement can take time. Tackling obesity in our younger people isn’t remedied in a single budget year. Commissioners, working with the wider health and care system, can show leadership in agreeing multi-year budgets to give providers greater certainty and encourage a focus on long-term health gain. This approach can also be a catalyst for greater provider innovation and give confidence for investment for long-term gain.

3. Commission for improved outcomes for patients and greater value for the taxpayer
We have seen encouraging signs of commissioners taking the initiative and moving towards a value-based approach to commissioning. This approach focuses on the right care at the right time for the same or reduced cost. This is more powerful when combined with clear segmentation and contracts awarded over multi-years. We would also encourage a more frequent dialogue with regulators to make the most of their insight to flag potential concerns or indeed successes that can be spread.
This approach is gaining traction internationally as the commissioning approach becomes more sophisticated in response to the changing needs of the population.

4. Inclusive commissioning for better care
Commissioners should not expect to know the solutions for all their challenges. An inclusive approach to commissioning will encourage the patient, service user, NHS providers and the voluntary sector to bring innovative solutions to the outcome challenges that commissioners set out. A good example is the approach Apple has taken with its App Store, which has created a vehicle for thousands of innovative applications to be crafted. Unleashing the talent and innovation of the public and provider organisations could be a similar game changer for commissioners.

5. Use clinical insight to drive change
The strong clinical leadership across commissioners has been the real differentiator from the primary care trust (PCT) era. The challenge is to ensure that the clinical leaders are not drawn into the bureaucratic minutiae that organisations create and instead focus on adding value based on their experience. It’s a well-used phrase but the future is indeed already here, it is just not very evenly distributed. Clinical leaders can bring insight from where clinical practice is developing to help ‘future proof’ the commissioning decisions. The significant fall in costs for genome technology, for example, is heralding in a new era of personalised treatments and therapies. The rise in cancer survival rates is due in part to the more sophisticated – and personalised – targeting of tumours with drugs that are tailored to the individual. Clinical leaders in commissioning can help interpret these developments and understand how commissioners can maximise their impact for outcome and value.


We hear numerous examples of relationships being built across health systems with clinical commissioners leading the way.

6. Commission for new models
Actions one to five in this article may help transform the commissioning landscape. One of the consequences may mean that current delivery models are no longer fit for purpose in an age when people are living with long-term conditions that require very few hospital interventions. Like integration, new models are not an end in themselves but commissioners can encourage innovative ways of delivery to improve outcomes and release added value. The Five Year Forward View sets the ambition and provides permission to innovate to meet local needs. Commissioners can be the catalyst for this step change improvement. The recently announced vanguard sites can be part of this change. Understandably, many of the selected sites are already considered to be among the best in the country. The challenge for commissioners and the wider NHS is to spread this practice and learning to others. The NHS track record in this regard is not consistently excellent. Commissioners can pick up the torch here and encourage the development of multi-specialty provider groups focused on addressing the health needs of the local – segmented – population.


So, what does this manifesto mean for commissioners across the NHS? If we had a seventh action it would be that now is the time for bold leadership to provide vision and clarity of purpose to deliver better care and value. l

Gary Belfield, head of commissioning at KPMG, and John Howard, head of commissioning support at KPMG.

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