1. Where next for commissioning in
the NHS?
Nuffield Trust Annual Summit 2011
Judith Smith
March 2011 © Nuffield Trust

2. ‘Weaknesses remain, 20 years after the introduction of the purchaser-
provider split. Commissioners continue to be passive, when to do
their work efficiently, they must insist on quality, and challenge the
inefficiencies of providers, particularly unevidenced variations in
clinical practice.’
(Health Select Committee Inquiry, 2010, p38)
March 2011 © Nuffield Trust

3. ‘There is little substantive research evidence to demonstrate that any
commissioning approach has made a significant or strategic impact on
secondary care services’
(Smith, Mays, Dixon, Goodwin et al, 2004)
March 2011 © Nuffield Trust

4. ‘Purchasing health services is inherently difficult in publicly financed
health systems.’
(Mays and Hand, 2000)
March 2011 © Nuffield Trust

5. Commissioning: a peculiarly English obsession?
• A term we use in the NHS in England for what others call
strategic purchasing, paying, or planning and funding
• Linking available funding to services provided has to be done
somehow
• We have chosen, for 20 years, to do this via a purchaser-
provider split
March 2011 © Nuffield Trust

6. And we seem committed to its retention...
Purchaser-
8% provider split
should be
retained
Purchaser-
29% provider split
should be
63% abandoned
Don't know
Source: The Nuffield Trust: A Snapshot Survey of Health
Leaders on the Government’s NHS Reform (Forthcoming)
March 2011 © Nuffield Trust

7. Research points to a common set of problems:
• Asymmetry of information between providers and funders
• The power lies with (especially hospital) provider institutions
• Sorting out budgets and financial risk
• Securing high quality commissioning support
• Ensuring proper accountability for funding decisions, service
quality and outcomes
March 2011 © Nuffield Trust

8. Evidence on primary care-led commissioning
•It is effective in developing primary and intermediate care
•This happens through peer review, clinical governance,
development of care pathways, control of referrals
•It can lead to improved responsiveness on the part of
secondary care
•There is little evidence to show that it is effective in making
strategic changes to secondary care
March 2011 © Nuffield Trust

9. The current context makes things more difficult
• Economic hard times, where tough funding (rationing)
decisions need to be made
• We assert a need for more preventative and population
health-focused care (less reliance on hospitals)
• We are again reorganising commissioning (as we did in
1999, 2002, and 2006)
• The leaders’ survey suggests more faith in central and local
performance management, than in GP commissioning
March 2011 © Nuffield Trust

10. Choice of levers to achieve efficiency savings
More provider competition
13%
26% stronger central
performance management
13%
stronger local performance
1% management
GP commissioning
47%
Control of prices for
clinical care
Source: The Nuffield Trust: A Snapshot Survey of Health
Leaders on the Government’s NHS Reform (Forthcoming)
March 2011 © Nuffield Trust

11. Questions for us to ponder
• We are putting huge faith in GP commissioning – what will
be needed if these reforms are to deliver the efficiency
challenge?
• What will be the role of the NHS Commissioning Board in
relation to GP commissioning?
• What about the other commissioners of health: local
government, people holding personal budgets?
• Do we need to move beyond commissioning?
March 2011 © Nuffield Trust

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March 2011 © Nuffield Trust