Nina Buchan, Editor of Specialised Medicine, summarises highlights from the Westminster Health Forum conference on the future of commissioning health services in England
The Westminster Health Forum conference, The future of commissioning health services in England—integration, use of data, responding to COVID-19, and priorities for specialised commissioning, was held online on 18 August 2020.
Dr Karen Kirkham, Senior Medical Advisor, Primary Care Provider Transformation, NHS England and NHS Improvement, summarised the coordination of the response to COVID-19 and management of the challenges left in its wake. Prior to COVID-19, the health service was already considering new ways of working, forming new partnerships and adopting new technologies to achieve more integrated, personalised care. When the pandemic hit in March, it put enormous strain on healthcare services, but it also galvanised this aim to work collectively as a system.
During the pandemic, regulatory bodies, professional bodies, and NHS leadership supported rapid service transformation and empowered change at the local level. As acute services rapidly refocused to prioritise the treatment of patients with COVID-19, primary, secondary, and community healthcare settings underwent a digital revolution—remote consultations were adopted overnight as the safest way of delivering care to patients. In addition, there was greater communication between primary and secondary care and local authorities, and relationships were forged with community and voluntary organisations to bring care closer to people shielding at home. This collaboration between providers broke down the barriers of the preceding 20 years.
This collaboration between providers broke down the barriers of the preceding 20 years.
Dr Kirkham believed that, going forward, health services must cement these relationships to build on these successes. At the local level, remote consultations should continue to prevent unnecessary hospital attendances, although care should be taken to avoid digital inequality. Where care cannot be administered remotely, face-to-face appointments should be optimised. At the system level, a multidisciplinary approach, that includes out-of-hospital support, should be adopted to bring care closer to patients. In addition, patient pathways should be standardised to reduce variation and prevent silo working. A single care record across integrated care systems (ICSs) will also help patients to move more seamlessly through the system. Although changes to resourcing, workforce, and estates will be necessary, these service transformations will address health inequalities and enable more personalised, holistic care.
In conclusion, Dr Kirkham felt that the pandemic had strengthened some of the foundations of the healthcare system, and enabled a move towards joined-up care that was long overdue. However, she emphasised that, without action, new partnerships may be broken and silo working may return, and that it is incumbent upon leadership at all levels to embrace the principles of this testing time to ensure that the gains made are not lost.
Professor Pauline Allen, Professor of Health Services Organisation, London School of Hygiene and Tropical Medicine, provided an update on developments in the purchaser–provider split across the changing commissioning landscape. Professor Allen explained that, since the introduction of the Health and Social Care Act 2012,1 the number of bodies involved in commissioning had increased to include CCGs, NHS England, and local authorities. In addition, the number of regulators has also increased to include bodies such as NHS Improvement and the Care Quality Commission.
Consequently, the aims of the Act—to provide more freedom from government control and allow greater accountability to patients—have not been realised.1 Furthermore, the Act led to a fragmentation of commissioning that has negatively impacted the delivery of services and patient outcomes. The efficiency of the system has been adversely affected by its complexity, and the costs of transactions are high. Professor Allen believed that, in the years that followed, the opportunity to reknit pre-existing systems has been lost.
Although no legislative changes have been made as yet, it is an ambition of the NHS Long Term Plan that all parts of the country will become part of an ICS by April 2021.2 Given the changes planned, commissioning is unlikely to continue in its current form. However, Professor Allen believed that commissioners will still be needed for tasks such as between-provider resource allocation and monitoring. Rather than asking whether there will be a role for commissioning in future, the real question is at what level commissioning will occur—local or national—with the answer determined by the needs of local populations.
… it is incumbent upon leadership at all levels to embrace the principles of this testing time to ensure that the gains made are not lost.
David Stout, Interim Chief Executive, Shropshire Community Health NHS Trust, spoke about the future of commissioning in light of ‘system by default’, learning from COVID-19, and potential legislation. As mentioned earlier, CCGs will merge to form ICSs by April 2021 as part of efforts to adopt a population health‑based approach to service redesign. As a result, the commissioning of services will pass from commissioners to providers over time. Some posts will stay, such as those dealing with monitoring and service quality, whereas others, such as those related to service redesign and partnership working, will transfer to ICSs. In theory, this will future-proof services, allowing them to focus on outcomes and work less competitively and more collaboratively.
Mr Stout believed that the NHS had shown common purpose during the COVID-19 crisis. Partnership working increased dramatically, and the temporary suspension of Payment by Results and other financial restrictions had enabled service transformation. This collaborative approach foreshadows the mode of operation of ICSs and the ‘system by default’ model of running and organising the NHS—both of which are core ambitions for the future of the health service.3 Mr Stout said that he expected legislative changes to follow NHS England’s permissive approach to collaborative working, which would recast ICSs as statutory bodies and give them the power to intervene in cases of provider failure.
The future of commissioning will vary in different areas of health and social care. However, Mr Stout said that commissioning will still be necessary in future because strategy, funding, and monitoring will always be needed, however the NHS is structured. In the future NHS, commissioners will become custodians for the taxpayer, with accountability to the population.
Professor James Kingsland, National Primary Care Home Clinical Director, National Association of Primary Care and Executive Chair, Institute of Healthcare Management, covered the next steps for delivering commissioning for complex needs and tackling health inequalities. Professor Kingsland began by highlighting the fact that many new models of care implemented in response to service reviews have not been sustained because of a failure to adopt and spread innovation. Consequently, the same needs for reform persist, but a lack of organisational memory has led to the same mistakes being made repeatedly.
Professor Kingsland cited the Marmot review, Fair society, healthy lives, the aim of which was to examine the evidence and advise on the development of a strategy to address health inequalities in England.4 A follow-up review conducted in 2020 has demonstrated that, in the 10 years since the original review was published, very little has been achieved in the way of tackling health inequalities, and that some inequalities have in fact worsened. In 2011, for the first time since the beginning of the 20th century, life expectancy stopped improving in the UK, and actually fell in some regions.5
The COVID-19 pandemic has compounded these existing disparities, and efforts to combat health inequalities must take into account the physical, psychological, and financial aftershocks of the disease—in previous pandemics, the greatest morbidity and mortality often occurred in the recovery period. Practical solutions are needed for recovery, and Professor Kingsland referred to the Sendai Framework for Disaster Risk Reduction, a global strategy to reduce and prevent disaster risk.6 The guiding principles of the framework aim to increase resilience to disasters by tackling factors such as poverty and inequality. The health service should adopt the approach of the framework to ‘build back better’ after the pandemic and address the wider determinants of health. However, Professor Kingsland noted that unequal things must be treated unequally—a centrally coordinated, one-size-fits-all approach is inappropriate when the health needs of regions of the UK vary considerably.
Professor Kingsland explained that the key to ensuring that service transformation succeeds and is sustained lies in creating the right environment for reform. He asserted that command and control is not the best way to bring about reform outlined in policy; rather, the teams doing the work should be given control over reform because they have the most relevant experience. Local leadership—‘finding the leader in the person’—empowers teams to institute change at place level. The first step is to understand the health needs of the population using data, then secure services against these needs, for which changes to resourcing and estates may be necessary. Monitoring of these services then ensures that change is implemented sustainably.
This conference report was prepared by Specialised Medicine and the speakers have not had the opportunity to make corrections.
- HM Government. Health and Social Care Act 2012. London: HM Government, 2012. Available at: www.legislation.gov.uk/ukpga/2012/7/contents/enacted
- NHS England. Designing integrated care systems (ICSs) in England—an overview on the arrangements needed to build strong health and care systems across the country. London: NHS England, 2019. Available at: www.england.nhs.uk/wp-content/uploads/2019/06/designing-integrated-care-systems-in-england.pdf
- NHS England and NHS Improvement. NHS operational planning and contracting guidance 2020/21. London: NHS England and NHS Improvement, 2020. Available at: www.england.nhs.uk/wp-content/uploads/2020/01/2020-21-NHS-Operational-Planning-Contracting-Guidance.pdf
- The Marmot Review. Fair society, healthy lives. London: The Marmot Review, 2010. Available at: www.parliament.uk/documents/fair-society-healthy-lives-full-report.pdf
- Institute of Health Equity. Marmot review 10 years on. London, IHE, 2020. Available at: www.instituteofhealthequity.org/resources-reports/marmot-review-10-years-on
- European Commission. Sendai Framework for Disaster Risk Reduction 2015-2030. ec.europa.eu/echo/partnerships/relations/european-and-international-cooperation/sendai-framework-disaster-risk-reduction_en (accessed 19 August 2020).