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The landscape for NHS commissioning is changing

By Ruth Robertson
9 April 2019

While commissioners and providers remain separated in law, the line between the two is becoming increasingly blurred in practice, Ruth Robertson senior fellow at The King’s Fund explains her views.

The new models of care brought together organisations from different parts of the health and care system to test out new ways of delivering care in a more coordinated way.

At the moment, we are seeing integrated care systems (ICSs) attempting to bring together commissioners and providers to plan and pay for services more collaboratively.

These changes are happening in spite of the legislative framework of the NHS, rather than because of it.

The Health and Social Care Act 2012 strengthened the purchaser–provider split by enshrining elements of the internal market in legislation. That’s why NHS England and NHS Improvement recently published proposals for new legislation designed to make implementation of the long-term plan – which focuses on collaboration rather than competition – easier and faster.

Last month The King’s Fund’s project director Ben Collins published a new report, that examines the use of incentives in the NHS – a key element of the purchaser – provider split and the competition-based internal market.

The report describes how for 30 years, policymakers in the healthcare sphere have been convinced that financial incentives can create a self-improving NHS, but their attempts have failed.

It asks why we think the new payment models that are being developed by the national bodies to support integrated care will be any different and warns that there are significant unresolved difficulties in applying the type of incentive scheme developed for accountable care in insurance-based health systems to tax-funded health systems with state-owned providers and limited choice of provider.

The report calls for urgent reform and simplification of the system for paying and contracting services in the NHS, to free up local systems to focus on collaboration and improvement.

But what does this mean for commissioners? However the functions currently referred to as commissioning change over the next few years, most of the key tasks involved (which are often summarised in the commissioning cycle) will continue.

It may be that providers start to take on some of these activities or that new organisations – like the ICSs – become responsible for them, the way some activities are carried out some might change, and some may no longer be relevant.

However, every health system (including those, like Scotland, that do not have a purchaser–provider split) needs people to assess local needs and then plan, develop and monitor services – whether or not we call them ‘commissioners’ and whether or not they work for ‘commissioning’ organisations.

There is a risk that, as local systems develop new structures and systems for planning care, they throw the baby out with the bath water.

CCGs may not have wielded much power over big acute trusts but while it’s important that providers and commissioners collaborate to promote improvement across systems, there still needs to be some grit in the system to ensure providers are held to account.

Ruth Robertson is senior fellow at The King’s Fund

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