How can ICB commissioning succeed where previous attempts have failed?

Many commentators, myself included, have questioned the wisdom of reorganising the NHS at a time when there needs to be a relentless focus on improving health and care. Equally questionable is the decision to recast the role of integrated care bords (ICBs) as strategic commissioners in view of the difficulties encountered in commissioning in previous NHS reforms.

Numerous reports have highlighted the weaknesses of commissioners and the challenges they have faced in leading change and improvement. The reasons include the complex nature of healthcare delivery, information asymmetries between commissioners and providers, and lack of technical and managerial skills. Similar factors explain the disappointing track record of commissioners and payors in healthcare systems in other countries.

Designs on world-class commissioning

Recognition of these factors led the last Labour Government to launch a programme designed to promote world-class commissioning in the NHS in 2007. The programme was intended to strengthen the role of primary care trusts (PCTs) by developing the competencies they required to perform effectively. The formation of the Coalition Government in 2010 sounded the death knell for PCTs, by which time an assessment by the House of Commons Health Committee concluded that many PCTs believed they were working more effectively than the evidence suggested.

While it is possible that the world-class commissioning programme might have strengthened commissioning if more time had been allowed for it to work, other constraints should not be overlooked. Research into total purchasing pilots in the NHS published in 2001 reported that pilots with the highest management costs achieved the best outcomes. This underlines the need to ensure that sufficient resources are available to recruit staff with the skills required to deliver results.

These skills include clinical expertise of different kinds and the ability to gather and analyse data. Technical competence should go hand in hand with soft skills if commissioners are to avoid adversarial relationships with providers and work in a way that is both collaborative and challenging. Nowhere is this more important than in bringing about improvements in specialist services, such as occurred in stroke care in London in 2010. 

“Commissioning can be more effective when it is based on trusting relationships rather than relying on contracts”

Concentrating these services improved patient outcomes and service delivery and is a rare example of commissioners leading major service change. A key lesson from this example is the way in which commissioners engaged stakeholders and worked to facilitate discussion among stroke specialists who were instrumental in developing options for the development of hyper-acute stroke units in the capital. By extension, ICBs will need to work effectively with provider collaboratives and primary care networks in making change happen.

Successful commissioning in practice

Commissioning can be more effective when it is based on trusting relationships rather than relying on contracts. This is underlined by the experience of the Canterbury Health Board in New Zealand, widely recognised as a pioneer in the development of integrated care. Leaders in the board and staff invested time in building understanding and breaking down barriers to communication to underpin their work. Contract documentation was kept to a minimum in line with the mantra of Canterbury aspiring to be ‘one system with one budget’.

Relational contracting is especially important when it comes to deciding how resources are allocated. Aligned incentive contracts of the kind developed initially in areas such as Bolton and Leeds are a practical illustration of how this has been done. These contracts are based on a joint commitment by providers and commissioners to work together in using resources effectively, while embracing objectives that relate to improving population health as well as care delivery. Staff involved emphasise the cultural change required to operate in this way.

“Leaders across the NHS must rise to this challenge and maintain a focus on patients and citizens rather than organisational self-interest”

Without arrangements of this kind, there is a risk that commissioner/provider relationships will consume time and energy without delivering the shifts expected to be at the heart of the ten-year health plan. In place of transactional behaviours, the emphasis must be on collaboration and a belief that partnership working is the best way of bringing about change. Leaders across the NHS must rise to this challenge and maintain a focus on patients and citizens rather than organisational self-interest.

The new NHS anatomy

These lessons should inform a development programme aimed at supporting ICBs to live up to the expectations set for them. As this happens, work is needed to enable ICBs to engage in learning networks to allow emerging good practice to be spread and adapted effectively and rapidly. For its part, the new centre and its regional offices should avoid acting in a way that encourages behaviours that run counter to the evidence and experience summarised here.

Now is the time to revisit work on the new operating model for the NHS, taking account of the seismic changes that have been announced in recent weeks. The new anatomy of the NHS must be underpinned by a physiology that recognises the need to combine top-down and bottom-up leadership. Ministers and their advisers should resist the temptation to manage through the hierarchy and follow through on their stated intention to devolve decision-making within the NHS.

Strengthening the role of commissioners is equally important. For this to be more than a triumph of hope over experience, work must start now on capability building.

Chris Ham is emeritus professor of health policy and management at the University of Birmingham.