Kidney surgery

Clinical commissioning and the NHS internal market

By: Ben Gowland @ccginsider
Published: Monday, September 1, 2014 - 07:53 GMT Jump to Comments

Like it or loathe it the NHS has an internal market, and it is the job of CCGs to make this market work in the best interest of patients and taxpayers.

One of the things I find most difficult is explaining to people what I actually do. When I am out with friends and they ask me what my job is and I reply that I am a ‘commissioner’ of health services, the blank looks on their faces makes it clear that as a descriptor it fails miserably on the Ronseal - does what it says on the tin - scale of packaging clarity.

I was reminded of this recently when I saw some friends a few months after having explained my role to them, and they asked if my work had now come to an end – assuming that by ‘commissioner’ I had meant ‘contractor’, and was therefore only temporarily assigned!

So what is the best way to explain commissioning? It is not possible to explain it without starting with the internal market in the NHS. Despite being introduced 24 years ago through the 1990 NHS and Community Care Act, it is not something that is widely understood.

Put simply, the government receives funding for the NHS via taxation. The government gives the money for the NHS to organisations like mine, CCGs, to buy services from providers (like hospitals).  Our job is to establish effective contracts that ensure high quality, cost effective services are in place that meet the needs of the local population.

But why not give the money directly to providers like hospitals and community services? Why add all the cost of commissioning into the system? The intention is that having commissioners in place will enable an internal market: it will enable competition between providers; decrease costs; and increase quality and innovation.

The premise is that the NHS is more efficient and delivers better care as a result of being split into multiple purchasers who acquire care from a range of competing providers, rather than functioning as a centrally managed organisation. It was first set out in a White Paper, Working for Patients, in 1989, and commentators have argued about its effectiveness ever since.

The rights and wrongs of the purchaser provider split and the development of an internal market is ultimately one for the politicians. Developments in the internal market since 1990 largely took place outside of formal legislation and were enshrined in statute by the 2012 Health and Social Care Act, which was one of the reasons for the difficulties it endured in its passage through parliament. The fact is that now we do have a system whereby commissioners and providers are separate, and it is the role of CCGs to make the new system operate in the best interest of patients. 

So how do we do that, in practice? As CCGs have established themselves, they have developed different approaches. One is where CCGs try to harness the power of the market to improve quality and outcomes. Look, for example, at Cambridgeshire and Peterborough CCG’s five year contract for the care of elderly people worth £800M, or Bedfordshire CCG’s five year contract for musculoskeletal services worth £120M. 

Here market forces become the main driver for changes by providers. Providers are forced to change the model of service provision to react to the specification put out by the commissioner, or else risk losing the service to another provider who bids. 

An alternative approach is for CCGs to work in partnership with providers, in part through the contracts that they have with them, and in part through the knowledge and expertise of the GPs who are an integral part of CCGs, to work with consultants and nurses and other healthcare professionals, and patients, to develop new models of service provision and new ways of working that improve outcomes and experience for patients.

A key ingredient of the new post-2012 system, the x-factor of clinical commissioning if you like, is that when GPs change the way that they operate they impact the system as a whole. GPs are the gatekeepers of the system, the ones with long term relationships with patients in place, and CCGs that can use this as a lever to drive change are the ones that are most likely to be successful.

While there are different approaches, CCGs do not need to choose one approach over another.  Rather they need to be able to use a range of different approaches to influence the way that healthcare is delivered, by whatever means they can, to secure the best outcomes and maximum possible value for the patient and for the taxpayer.

So the job of the commissioner in the NHS is to preside over the internal market. For a whole set of reasons the internal market in the NHS is not something that is widely talked about, and is not recognised or understood by much of the population.   think this is what sits at the heart of making my job difficult to explain. As I am sure Joe Tibbetts, my co-presenter on the RealityBites podcast will tell me, it is probably no clearer now than it was when I started trying to explain it…

REALITYBITES - The National HealthCare Conversation is published as a podcast every Monday morning. Listen, download or subscribe on the front page of The information Daily.

The views and opinions expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of The Information Daily, its parent company or any associated businesses.

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