Commissioning for sustainable

healthcare

Tom Ling, RAND Europe

Paris, OECD, 4th February 2016

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The following issues will be addressed:

1. How (good) commissioning is seen in England and what is

expected of it

2. How commissioning contributes to sustainable healthcare systems

3. Examples of how this works in England and where strengths and

weaknesses lie

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What is commissioning, what is

hoped for it?

Commissioning:

• Changes the transaction between members of the public with needs and the agencies responsible for meeting those needs

• Has much in common with: ‘purchasing’, ‘procurement’, ‘contracting’, ‘strategic purchasing’ and ‘competitive tendering’

• Typically involves the retention of a monopoly of public financing

• OECD helpfully distinguish between passive and strategic

The hope in England is that Commissioning will:

• Create a champion for personalised or (otherwise) high standards of care

• Create competition and innovation to meet needs more effectively and efficiently

• Temper the risk of (self-serving) providers delivering poor quality or even abusive care

• Facilitate long-term planning and more preventive work to improve outcomes for given level of expenditure

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The commissioning system in England

Source: House of Commons Library

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Commissioning system in England

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Not pursued throughout the UK

– (Many) people in Scotland believe they get better care by encouraging

collaboration among providers, by focusing on maintaining and

improving standards, and supporting quality improvement activities

– Scotland and Wales abandoned the purchaser provider split in 2004

and 2009 respectively (and Isle of Wight never adopted competitive

model)

– Northern Ireland has a ‘half-way-house’

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Most (English) versions of

commissioning cycle look something like

this:

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Where commissioning in England fits in

sustainable healthcare systems

New thinking,

services and technologies

Evidence and guidelines

Sustainable

health care

Efficient & effective use of resources

Commissioning and funding health services and service efficiency

Applying evidence, guidelines, managing and implementing

Innovation and improvement pipeline

RISING DEMAND RISING COSTS

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Perceived weaknesses in UK

commissioning architecture

New thinking,

services and technologies

Evidence and guidelines

Sustainable

health care

Efficient & effective use of resources

Commissioning and funding health services and service efficiency

Applying evidence, guidelines, managing and implementing

Innovation and improvement pipeline

Funding cycles and logics often fit poorly with delivery and prioritisation

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Sustainable healthcare systems: where

commissioning fits

New thinking,

services and technologies

Evidence and guidelines

Sustainable

health care

Efficient & effective use of resources

Commissioning and funding health services and service efficiency

Applying evidence, guidelines, managing and implementing

Innovation and improvement pipeline

Funding cycles and logics often fit poorly with delivery and prioritisation

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Sustainable healthcare systems: where

commissioning fits

New thinking,

services and technologies

Evidence and guidelines

Sustainable

health care

Efficient & effective use of resources

Commissioning and funding health services and service efficiency

Applying evidence, guidelines, managing and implementing

Innovation and improvement pipeline

Funding cycles and logics often fit poorly with delivery and prioritisation

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UK commissioning today – searching for solutions

– but weakly developed commissioning for

innovation and improvement

New care models,

services and technologies

Evidence and guidelines

Sustainable

health care

Efficient & effective use of resources

Commissioning and funding health services and service efficiency

Applying evidence, guidelines, managing and implementing

Innovation and improvement pipeline

New models of care, integrated care organisations, IPCs all CCGs to implement NICE guidelines, etc.

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UK commissioning today – searching for solutions

– but weakly developed commissioning for

innovation and improvement

New care models,

services and technologies

Evidence and guidelines

Sustainable

health care

Efficient & effective use of resources

Commissioning and funding health services and service efficiency

Applying evidence, guidelines, managing and implementing

Innovation and improvement pipeline

New models of care, integrated care organisations, IPCs all CCGs to implement NICE guidelines, etc.

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UK commissioning today – searching for solutions

– but weakly developed commissioning for

innovation and improvement

New service models,

devices and medicines

Evidence and

guidelines

Sustainable

health care

Efficient & effective

use of resources

Commissioning and funding health services and service efficiency

Applying evidence, guidelines, managing and implementing

Innovation and improvement pipeline

New models of care, integrated care organisations, IPCs all CCGs to implement NICE guidelines, etc.

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UK commissioning today – searching for solutions

– but weakly developed commissioning for

innovation and improvement

Search frictions

Misaligned incentives

Sub-optimal commissioning

Principal agent problems and risk aversion

Commissioning and funding health services and service efficiency

Applying evidence, guidelines, managing and implementing

Innovation and improvement pipeline

New models of care, integrated care organisations, IPCs all CCGs to implement NICE guidelines, etc.

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Looking forward…Kings Fund say a

commissioning strategy should include: • a compelling vision for the future, underpinned with clear strategic

objectives reflected in an explicit statement of desired outcomes and

key performance indicators

• a clear statement of the organisation’s purpose and approach that

takes appropriate account of the external context

• a perspective which balances national and local priorities

• evidence that the strategy has been shaped by the ‘intelligence’

made available to the governing body

• demonstrable links to the needs of users, patients and communities

• a longer term view (with at least three to five year planning horizon)

including a long-term financial model and risk analysis.

http://www.kingsfund.org.uk/sites/files/kf/Good-governance-for-Clinical-Commissioning-

Groups-Introductory-Guide-December2011.pdf

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Kings Fund outline is helpful but misses

how commissioning sits within the

wider architecture of sustainable

healthcare • Market intelligence

– to understand supply and demand

• Market structuring

– to shape market behaviour

• Market intervention

– to deliver the kind of services needed by the community

• Providing signals and incentives for long term innovation and

improvement including investing for future benefit and to achieve

savings for others and in addition…

• It requires clear and consistent messages, fairness in competition,

and relationship-building with provider

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The example of Integrated Personal

Commissioning

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Achieving a long term shift in provision

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Alongside a long-term shift in demand

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Commissioning in England –

strengthen further alignment with other

drivers?

Source: House of Commons Library

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