Commissioning is changing…is it time for a new definition?

Commissioning is changing right before our eyes – and I would say changing for the better. If there’s one thing I’ve heard very clearly from our members of late, it’s their drive to build on the good work done through their planning and coordination roles during COVID-19 and their determination to evolve commissioning to a strategic level for the benefit of their populations.

Commissioners have been on a bit of a journey in recent years. Clinical commissioning groups (CCGs) were established in 2012 with a lot of ambition to be population focused and clinically driven. Their population size suited place-level working, particularly with local government, but found it more difficult to lever influence at scale. They also knew early on that contracting in its current transactional form was not what changes mindsets, improves outcomes or creates the right tone for collaborative working.

The first time our members tried to define the nature of strategic commissioning and what it does was in 2017 when we launched Steering Towards Strategic Commissioning. Here we articulated some specific functions, including population level needs assessment, outcomes-based commissioning, resource allocation, strategic procurement and holding the delivery system to account. At its heart was a desire to preserve clinical voice and its unique input into commissioning functions that has developed via CCGs. We argued that clinicians bring a level of credibility to a plan or objective that otherwise wouldn’t be there. This was at a time when strategic transformation partnerships (STP) were forming new landscapes which were bigger than CCGs.

And so the journey continued …the NHS Long Term Plan (LTP), the development of integrated care systems (ICS), system by default and COVID-19 has all made commissioners want a new ‘business as usual’. But our members are clear that this cannot happen in isolation - if commissioning changes into a more sophisticated set of functions, so too must the way care is delivered – it must be integrated at all levels and focus on place and neighbourhood to reach the specific needs of its populations.

To support CCGs to learn and share from each other at this point in their journey, we recently held a webinar on approaches to what we call ‘streamlined commissioning’; that is the work being undertaken locally to move commissioning functions to the most appropriate population level.

A few things struck me. We heard from NHS England and NHS Improvement, that the move to operating as systems was very much an iterative process, focused around place-level delivery and that now was the time to influence the national policy around it. This was encouraging as in effect CCGs are now encouraged to rethink their commissioning functions and ‘master their own destiny’ so long as it sits within the principles of system working and the LTP.

We also highlighted some work in progress from a few CCGs - South London CCG, Nottingham and Nottinghamshire CCG, Bath and North East Somerset, Swindon and Wiltshire CCG and STP. It’s clear that all of our case studies had made considerable strides to do the right thing and take a deep dive into the core purpose and functions of commissioning in light of STP and ICS development. This is a brave thing to do. This was about creating a new operating model that redefines commissioning and places it in the new world. What that means in reality is that there will be a specific journey that each integrated care system must go through with its delivery partners (including local government). That is to:

• define what behaviours work to improve health and care outcomes for their populations
• identify new approaches to decision making between partners – some at place some at system
• engage the broader clinical community and move from statutory structures to partnership working in its true sense.

This is about the commissioner role working with complexity, being coordinative, collaborative, empowering, and trusting its partners to deliver.

Within our webinar we were also reminded that there are a number of factors CCGs need to be aware of in the move to system working. The first is that with the increase in provider-provider and provider-commissioner collaboration, we must not let the innovation stagnate and aligned incentives must be built at every level of delivery. Secondly, while a focus on outcomes is good, it’s important to have some process measures which identify the direction of travel for public confidence when undertaking a strategic planning role.

So, what does this all mean for the months ahead? April 2021 is a critical point for full ICS coverage across England. For me, we need to remember that it is policy evolution not revolution that will reap the biggest benefits for our populations and this is very much the case for our members. It is clearly time for a new definition of NHS commissioning - one that operates at scale and supports systems to improve population-level outcomes.

NHSCC will be holding its annual national member event virtually on 12 November. If you are a member and wish to attend see the booking details.

Julie Das-Thompson is assistant director for policy and delivery at NHS Clinical Commissioners. Follow the organisation on Twitter @NHSCCPress