Nicholas Hunt is director of service development at Royal Brompton and Harefield trust.
This article was first published in the Health Service Journal on 08 January 2009.
Since the first statement of intent from the Department of Health back in December 2007, world class commissioning has grown rapidly from concept to, some might say, mantra.
As it continues to provide focus for providers and commissioners alike, one sector of the NHS could be forgiven for feeling a little pleased with itself. Specialised commissioning is in many ways ahead of the curve, an unsung success story of recent health reforms. Lessons can be learned across the NHS.
Following the Carter report of 2006, specialist groups now manage, or are beginning to manage, the commissioning of high-cost, low-volume interventions carried out at tertiary centres around the country.
"We can demonstrate very real savings to the health economy through close working with specialist commissioners"
At Royal Brompton and Harefield trust, we offer highly specialised services for patients with cardiac or respiratory disease. Recent years have seen major improvements in the specialised commissioning of treatments for cystic fibrosis, congenital heart disease and severe asthma, to name but a few of our specialist areas.
Poor understanding
Like other tertiary centres, we provide services for every primary care trust in the country. But following the purchaser-provider split, we began to suffer from a lack of commissioning knowledge about our services and a lack of understanding of the importance of tertiary and quaternary services in care pathways and care networks. (I should add that our host PCT has always been an honourable exception to the rule.)
Being located hundreds of miles from many of our commissioners did not help, but the principal reason for the knowledge gap was that we did a very small amount of work for each PCT, which made us a relatively low priority compared with big local district general hospitals.
Perhaps it was unrealistic to expect the necessary level of expertise - but at times the lack of understanding about our services was significant. I remember encounters with PCTs that confused cystic fibrosis with cerebral palsy; being on the receiving end of reprimands for failing to file orthopaedic waiting list returns (remember, we are a heart and lung centre); being told - not asked - to stop taking referrals because we were too expensive (in an age of national tariff); receiving requests for daily updates on patients in intensive care to help predict resource implications; and just dozens and dozens of unreturned telephone calls, unanswered e-mails and cancelled meetings, often after setting off for the PCT headquarters.
Building relationships
But this has changed. The new world class commissioning support and development manual is quite clear that one of the principal duties of commissioning is to have very good formal and informal relationships with providers. Following reforms in specialised commissioning, this is already practised by our specialised and local commissioners. It means we have one commissioner for each strategic health authority, thus markedly reducing the need for meetings and paperwork and vastly improving communication and knowledge.
The best specialist commissioners have an understanding of pathways and networks. They know that many of our patients will be referred by a GP to their local district general hospital, and then to us, and that aftercare will most likely involve a programme of shared treatment including regular visits back to us and care under a GP.
Only by understanding the full system can commissioners hope to have any bearing on future direction. Thankfully, this is now frequently the case.
Quality focus
Under specialist commissioning, the focus has switched to performance, quality and outcomes rather than the previous welter of questions relating to what were small blips in activity to us, but probably quite big blips for individual PCTs. And with this change of emphasis, the commissioning culture of trying and failing to control expenditure by raising lots of data queries is well and truly over.
Conversely, we can demonstrate very real savings to the health economy through close working with specialist commissioners. For example, we will try not to refer a patient back to a district general hospital if possible, but rather aim to manage their care directly back into the community.
The other great advantage to commissioners is that the greater degree of knowledge they have developed requires providers to be more accountable to them than under the previous system. We know we are now compared with similar providers nationally and internationally.
Improving access
For patients, there are also important benefits. Specialist commissioning facilitates individual choice, diluting any postcode lottery effect and helping to ensure specialist services are available to all. The fact that a service is specialist does not mean it should be difficult to access.
Change in the health service often attracts criticism. But as the NHS prepares to integrate the next stage review and embrace a constitution, reflecting on one of the more successful system developments in recent years offers useful learning opportunities.
Author: Nicholas Hunt.
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