What is commissioning?

We all 'commission' with our own money and for our own needs. But as guardians of the public purse, NHS commissioners have far greater responsibilities; their goal is the provision of equitable access to cost effective, value-for-money services to meet the needs of the population served, delivering the best possible outcomes, including reduced inequalities, all within the resources available. The three elements are procurement, planning, and performance monitoring.

Procurement

The currency of NHS contracts drawn up between the commissioners and the providers of health care is service specifications based on national standards and clinical guidelines. These determine the nature of treatments and therefore the costs.

Procurement is increasingly governed by payment by results (PbR) with national tariffs set for health related groups (HRGs) of procedures and diagnoses: once a patient is sent to hospital, a tariff payment is due. For more information see Table 1. Some types of care and elements of care (such as high cost drugs and certain medical devices) remain outside of tariff and are subject to local negotiations.

Tariff determines the price paid but not the nature of the care given. Creating service specifications first requires setting out a patient care pathway, which is part of the planning process.

Planning

Planning has at its heart epidemiology: the study of the patterns of diseases. It is the equivalent of market research. Besides identifying the need of the local population (broadly in the form of diseases or the potential to develop diseases) it is also necessary to understand what interventions are available that they would benefit from. There is no point in providing an intervention that brings no benefit. So a major part of planning is the assessment of effective available interventions and treatments. Ideally this assessment should also include health economics but such information is sparse. Nonetheless there must be an attempt to judge value for money, using whatever information and techniques are available. All the various specifications with their costs and the expected volume of activity must be brought together and matched to the overall budget. If that budget is exceeded, priorities will have to be agreed on: a necessary, inescapable process when needs exceed resources, which has been sadly demeaned by the word 'rationing'.

Local delivery plan

The process of considering need, identifying effective interventions, and prioritising them all against a budget (over whatever timescale has been set) results in the local delivery plan (LDP). The LDP is central to a primary care organisation's function: for it to stand any chance of managing its budget, everything should have gone through this process. This may seem overly bureaucratic and rigid, but it is essential for good financial management. A primary care organisation cannot technically exceed its budget: any overspend in any one year can only be addressed by borrowing from a future year. The only way additional funding can be found is to reduce activity elsewhere—that is, not treat another patient.

Performance monitoring

In monitoring performance, commissioners must take care to use valid measures, and contract activity information must be checked for accuracy. Is the activity and associated charge valid? Is the pattern of activity what's to be expected from national averages and norms?

For the most part, performance will be monitored by process measures set against agreed pathways of care. Other measures of performance will be taken on trust and built into contracts, such as clinical audit (with other bodies, not the commissioners, responsible for monitoring). When true outcome measures are used, such as infection, re-admission or postoperative death rates, it is essential appropriate techniques are used to analyse these figures.

There is much criticism of the attempts to secure high quality data in the NHS, ¹ but that criticism must be directed at the process, not the principles and the goals. High quality data are essential for the efficient running of the NHS and its collection in a useable form has been neglected for too long. High quality clinical data will deliver huge patient benefits as epidemiologists begin to get a better understanding of diseases from the data currently locked away in paper records. High quality data will also mean that the quality of care for an individual (via the pseudo-anonymised NHS number) can be monitored along the entire care pathway.

Ultimately the goals against which to judge success of commissioning over time are:

• Improvements in health and well-being
• Reductions in health inequalities and social exclusion
• Better access to a comprehensive range of services
• Improved quality, effectiveness and efficiency of services
• Increased choice for patients and a better experience of care
• Improved integration of health and social care
• Financial balance.

Contributors