Do you know what world class commissioning is? Neither do I. However, it seems to be the latest NHS catch phrase; tripping off the tongue of every NHS chief executive and political underling. At both the NHS Alliance and NICE conference last year, it was the first cross on my buzzword bingo card, and I wish I had a bag of Herceptin® for every time I heard it—but nobody could explain what it meant.
Let us start with its instigator—according to the Health Service Journal (HSJ), the third most important person in the NHS, in terms of his influence over policy and practice, is Mark Britnell, the Director General of Commissioning. The top two, in case you were wondering, are Chief Executive David Nicholson and Lord Darzi. Which means the backseat health secretary, Alan Johnson, is a mere fourth.1
The most telling statistic of the HSJ’s annual top 50 is that there were 26 new entries. Any business that cleared out over half of its top management every year would struggle to survive, but the good ship NHS somehow stays afloat in a sea of continuous change of policy and personnel. This year it is the rise of Britnell that is most notable.
He was the Chief Executive of University Hospital Birmingham at the mere age of 34, and oversaw a huge private finance initiative project (he even keeps a model of the building on his desk).2 Many see him as a future NHS Chief Executive, but currently he has the job of sorting out commissioning in Northern Ireland.
Apparently the health service underperforms every year because primary care trusts—who hold over 80% of the NHS budget—don’t get good value for money from the services they purchase.
On entering the DH, Britnell announced he would work out what needed to be done in his first 30 days, and how to achieve it in the next 30: the answer was ‘world class commissioning’. According to Britnell it includes ‘a Framework for procuring External Support for Commissioners (FESC), which is part of the ‘buy’ option, providing PCTs with easy access to a bank of specialist expertise in areas such as data analysis, contract management, and public engagement…’.3 The FESC could just be an excuse for clueless PCTs to buy the ‘expertise’ of huge for-profit health insurance corporations. In America these organisations keep costs down by offering doctors perverse incentives to deny patients the care they need. So far 600,000 doctors have been sued for this (pers. comm.), and there are widespread legal claims for misapplying fee schedules, errors in claims processing, and delayed payments.
Primary care trusts need to commission for the benefit of patients rather than to cut costs or maximise profits. They could start by refusing to pay hospitals for ‘foreseen and avoidable’ complications or illnesses. For example, if a patient developed a deep vein thrombosis or pulmonary embolus after surgery and hadn’t received adequate prophylaxis, the hospital would have to pay for the treatment (as well as the law suit). Likewise, if a patient was admitted to hospital just to hit a government casualty waiting target (this is estimated to have cost England £2 billion over the last five years),4 the PCT would only pay if there was proof that the admission was clinically necessary.
If PCTs or practice-based commissioners only paid for treatments where the providers could show that patients had benefited, the unproven political guff and bad medicine would disappear and the NHS might actually improve.
- www.chks.co.uk/ G
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