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Commissioning

Key Points Background Implications News Resources Action Points References

Key Points

The UK has seen radical reform to the structuring and delivering of public services, in order to enhance quality and secure good value for money.

Commissioning is one approach that has emerged from these reforms. Commissioning is used differently in each country within the UK, to secure either health services or other services that may involve physiotherapy.

This means that all physiotherapists need to understand how commissioning works, and what it means for physiotherapy.

  • Commissioning is a process that involves assessing strategically what services are needed, reviewing existing provision, setting priorities and planning, specifying and procuring services, engaging with local populations and patient groups to identify patient requirements for services, and finally developing and performance managing services.
  • Commissioning is most often carried out by local authorities or health bodies, who manage contracts with statutory or NHS departments and other private, public and third-sector providers.
  • Commissioning for healthcare services already takes place in England, and is being introduced in Northern Ireland in late 2010. In Wales and Scotland, commissioning is not used for healthcare services, but is used for other services that may involve physiotherapy – such as some local authority social care services.
  • Commissioning is intended to ensure 'best value' healthcare services, reduce inequalities, and enable a sharpened allocation of resources on the basis of patient need. It is a local process through which commissioners' work to nationally set targets while also making decisions regarding local priorities based on the needs of their local populations. This involves deciding what share of the overall resource to devote to each specific area of healthcare, and within those, how much to spend on surgery, drug regimes and prevention. The system also gives local organisations responsibility for deciding which aspects of care will not be provided within a particular locality.
  • Commissioning can often involve competitive tendering. This is designed to drive quality and efficiency by creating 'competitive tension' between potential providers. The idea is that because providers are anxious not to let standards fall as this may affect their reputation or contract retention, they will ensure a good service for a reasonable price. The jury is out on whether this has in fact happened.
  • Even in services that do not undergo a commissioning process, there appears to be a cultural shift towards values associated with commissioning. Across the board, physiotherapy managers are increasingly expected to demonstrate that they provide a cost-effective, quality response to patient needs that integrates seamlessly with other services to meet a range of wider health targets. It is therefore critical that all physiotherapists understand how to respond positively to the demands that this presents.

Implications

Despite the wide variety of approaches across the UK, there is a cultural shift towards commissioning-style values. Even where services are not commissioned, governments are driving an increasingly strategic approach to designing and delivering services, and we are seeing increasing levels of commissioning-related language and models in service planning.

Meanwhile, even in Wales and Scotland some social services that involve a physiotherapy role (such as back-to-work schemes) do undergo a commissioning process. For this reason it is important that all physiotherapists feel confident about what commissioning is, and how it works.

Commissioning raises both opportunities and challenges for physiotherapists. For details, see the section for your own country. To see some of the ongoing debate around the commissioning agenda, see our Frontline article: Commissioning: opportunity or threat?

The CSP has always believed that collaboration and communication is the best way to deliver services.  It strongly supports service re-design and innovation aimed at improving patient care but also believes that mainstream NHS services are best delivered by NHS employed staff.

CSP members have always worked in the public, private and voluntary sectors and the CSP recognises that no one sector has a monopoly on quality and innovation. It is important therefore that the CSP's longstanding policy of wanting to see mainstream NHS services retained in the NHS is seen in this context.

In a policy statement on Transforming Community Services agreed in 2009, CSP Council agreed that any change to organisational structures for community services must be reached only after proper consultation with all relevant stakeholders, including current NHS staff and their representatives. Any decision to transfer services out of the NHS must be backed by:

  • demonstrable evidence that the alternative provider will deliver better patient care than NHS services
  • a consultation that includes genuine choices between alternative providers and NHS services
  • a fully informed and proper consultation with CSP members and their CSP representatives.

Background

Commissioning is a long-term, cyclical and strategic process that involves assessing the service needs of the population, and then specifying, securing and monitoring those services, to deliver outcomes that address those needs.

Commissioning within the NHS has its roots in the internal market – a system through which different parts of the same organisation trade their services with each other. This system was first introduced to the NHS in the early 1990s by the Conservative government, which introduced competition in order to drive up quality and reduce cost, superseding the planning processes of an older, centrally directed NHS. At first, the ensuing Labour government abolished many of these changes, but by the early 2000s it had begun to reinstate some of these ideas, by prioritising policies such as patient choice.(1)

However, the shift was not universal. Following devolution, each of the four countries of the UK had begun to make its own way towards meeting its own healthcare priorities. An important stage of the journey was to decide how to identify needs, select services, and choose who would provide them. Each country has followed its own route, according to its unique set of principles.(2)

England favours market-based and technical approaches, so commissioning services in a competitive system fits with that approach. Northern Ireland favours democratic participation, neutrality and public health. Here, the emphasis is on people 'having a say' – and following a period of debate the commissioning model has now been chosen there too. In 2009 the Northern Ireland government created five new local commissioning groups, which will be responsible for commissioning healthcare services.

Meanwhile, Scotland and Wales favour collectivism, with an emphasis on collaboration in Scotland and communication in Wales. Both these countries have rejected the purchase–provider approach to managing healthcare services. Physiotherapists in these countries must demonstrate their effectiveness and value for money, but competitive tendering is not on the agenda for mainstream healthcare services.

The CSP provides joined-up advice from professional advisers and senior negotiating officers for members involved in major service redesign, or those who may want to campaign for a particular outcome. We are also developing further materials to assist members in making a business case and economic modelling to help promote their services and provide evidence of the value for money that physiotherapy offers. These will become available throughout 2010.

Action Points

  • Take some time to understand the key drivers in this field and how they impact on physiotherapy in your area. See the section for your own country for details.
  • Familiarise yourself with the information that determines commissioning priorities in your area. For example, this could include the vision of your local strategic health authority (SHA) and your local Joint Strategic Needs Assessment (JSNA), available from your local authority.
  • You need to be pro-active in seeking out information about what is happening in your area. For example, talk to key local stakeholders and influencers.
  • Get to know your local commissioners and find out what their priorities are, how they are working to commission health services, how decisions are taken, and the role of GPs in relation to practice-based commissioning. It may be useful and politically appropriate to ask for a shadowing opportunity.
  • Invite commissioners and local stakeholders to staff meetings to give a presentation about their priorities.
  • Make a clear and convincing business case for your services. Demonstrate how physiotherapy can generate whole-systems savings, through reducing or avoiding another cost.
  • Show how physiotherapy adds value, including its impacts on wider service delivery. Take advantage of the opportunities presented by commissioning to define the value of physiotherapy within the wider healthcare system, and collect persuasive data across a wide range of specialties, settings and services. (See Measuring for quality improvement in physiotherapy.)
  • Deploy information and data tactically. This means understanding the commissioning cycle sufficiently to use the data persuasively, focusing on the role of physiotherapy within the wider patient journey and packages of care, through integrated condition management and service delivery.
  • Use iCSP networks and this website to exchange ideas and experiences on commissioning with other members.

References

  1. Rivett G. National Health Service history Accessed: 28 January 2010
  2. Greer SL, Rowland D. Devolving policy, diverging values? London:  Nuffield Trust; 2008.
  3. Department of Health. Commissioning. Department of Health. Accessed: 28 January 2010
  4. Department of Health. About NHS allocations London:  Department of Health; 2009. Accessed: 28 January 2010
  5. Department of Health. The NHS plan: a plan for investment, a plan for reform. London:  The Stationery Office; 2000
  6. Scottish Executive. Building a health service: fit for the future. A national framework for service change in the NHS in Scotland. Edinburgh:  Scottish Executive; 2005
  7. Sturgeon N. Future of the NHS in Scotland: Health Secretary Nicola Sturgeon speech to the British Medical Association (BMA) July 8, 2008 Scottish Government 2008
  8. Feeley D. A mutual NHS. Scottish Government [2008]
  9. Department of Health Social Services and Public Safety. Health and social care reform. DHSSPS Modernisation and Improvement Programme Board (MIPB). RHSCB and RAPHSW - working together on a daily basis. MIPB 30/09. Belfast:  Department of Health Social Services and Public Safety; 2009
  10. Welsh Assembly Government. One Wales: A progressive agenda for the government of Wales. Cardiff:  Welsh Assembly Government; 2007
  11. Welsh Assembly Government. Fulfilled lives, supportive communities: a strategy for social services in Wales over the next decade. Cardiff:  Welsh Assembly Government; 2007

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The Chartered Society of Physiotherapy (CSP) is the professional, educational and trade union body for the UK's 50,000 chartered physiotherapists, physiotherapy students and support workers. Find out more about us.

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