Commissioning. Opportunity or threat?

Recent developments in health service provision have thrown up unprecedented challenges, as well as opportunities for the profession to flourish.

Like many other health professionals, physiotherapists now have to be business-savvy, able to make the case for services or risk seeing them wither.

The background

"All three major political parties are setting out their policies in advance of the general election and all three are proposing a continuation of the commissioning process in some shape or form" ~ Gary Robjent, CSP Head of public affairs and policy development Commissioning and competition in the NHS have long been touted as key drivers in raising standards of patient care and ensuring better value for money. The jury is out on whether these aims have been achieved but there is broad consensus among the three main political parties that this process should continue. There are now 152 primary care trusts in England that are responsible for spending over 80 per cent of the health service’s annual budget. The way that PCTs purchase, or commission, their services was shaken up with the launch of the world class commissioning programme in 2007. This introduced a range of core competencies that PCTs should strive for in their commissioning, alongside an assurance framework intended to measure performance and hold PCTs to account. The government’s drive to create an internal market in the NHS has now come one step closer with PCTs having hived off their community service arms under the Transforming Community Services programme.  PCT community services can remain part of the NHS as arms-length providers, seek community foundation trust status, merge with other PCTs or acute trusts, or they could be transferred out of the NHS to the private sector or voluntary sectors. PCTs are obliged to consider any request from staff who want to set up a social enterprise company to provide community services.

What’s happened so far?

World class commissioning demands that commissioners demonstrate 10 ‘competencies’ in their commissioning of effective health services. These include requirements to promote improvement and innovation, collaborate with clinicians, engage with public and patients, and work with community partners. This provides clinicians with the chance to ‘sell’ improved or newly-created services to commissioners, but it also gives commissioners the go-ahead to look outside the NHS in certain circumstances for the services they want to provide for patients. So far, this policy is in its infancy, and only the very earliest attempts to shift clinical services out of direct NHS control have been developed. A physiotherapy service commissioned by Camden PCT is thought to be one of the first where an existing NHS service has been put out to tender and the contract awarded to the private sector. The service includes clinical assessment and triage and direct-access musculoskeletal physiotherapy, including self referral.  Physiotherapy staff at the Royal Free hospital in Hampstead recently developed the service for NHS Camden as a pilot that lasted two years, and the service will be transferred to private sector management on 1 January 2010. There was no mechanism for staff consultation, and many physios who provide the service feel very aggrieved that what is regarded as a ‘high quality exemplar’ service, offering innovative care, became one of the first contracts to be transferred to the private sector. There have been concerns expressed that the decision many have been made largely on the grounds of cost. In a speech in September to think tank The King’s Fund, health secretary Andy Burnham indicated a significant change of direction in the commissioning debate, when he announced that the health service should move beyond arguments over private or public sector provision, to leave the NHS as the ‘preferred provider’ of health services. He said commissioners must test NHS services for quality and value for money. Where room for improvement is identified, NHS providers must be given the chance to do better, before those services are put out to tender. NHS chief executive David Nicholson has now written to all PCT and strategic health authority chief executives, with instructions that NHS staff should be involved in commissioning decisions, and that NHS clinicians should lead on service improvement and re-design, rather than having it imposed on them. This new emphasis on working with existing providers and doing more to engage with NHS staff is something that the CSP and other health unions have lobbied hard for.

What happens next?

To support the new ministerial policy, the Department of Health is to issue new guidance overriding current instructions on the ‘commercial operating model for the NHS’, as well as revising its guidance on PCT procurement, and the rules on cooperation and competition. However, this does not mean that commissioning from the private or third sectors will be abandoned, particularly where extra capacity or significantly new services are needed. What it does provide is a brake on what some had feared could be a rush by commissioners to embrace non-NHS providers.

Scotland, Wales and Northern Ireland

Both Scotland and Wales have rejected the purchaser-provider split in the management of their health services. Physios in those countries must demonstrate their effectiveness and represent value for money, but competitive tendering is not on the agenda (see Policy in focus, Wales, Frontline, 2 September). The Northern Ireland government created five new local commissioning groups earlier this year, which will be responsible for commissioning healthcare, but there will be no competitive tendering (see Policy in focus, Northern Ireland, Frontline 21 October).

What should you do?

  • commissioners now commission for outcomes. Commissioning then needs to be in line with strategic aims set out by the commissioners. Simply asking for extra physiotherapists to help improve a service, or develop a new one, is unlikely be enough. PCTs now make high-level promises on what they will deliver for their population in their operating frameworks and unless proposals for services can be shown to help meet these goals, those proposals are unlikely to be successful
  • commissioners will want proposals to be put in the context of local population need as outlined in joint strategic needs assessments
  • the vast majority of the information that determines commissioning priorities is publicly available, and physios can familiarise themselves with: their SHA Vision, Joint Strategic Needs Assessment, the world class commissioning assurance handbook, the commissioning cycle and the PCT, SHA and NHS operating frameworks
  • members should understand how to measure the cost,  quality and productivity of their service, be able to produce robust data including the views of service users, and be aware of how to explain it to a range of audiences
  • commissioners can be invited to staff meetings to talk for 10 minutes on a semi-formal basis on their priorities 
  • whether in the primary or acute sector, members cannot assume that just because they have not heard of proposed changes that nothing is being planned
  • by using the staff intranet, staff briefings and keeping in touch with their local CSP steward, members can do ‘homework’ on what proposed changes might mean for them in practice

What are the challenges  for physiotherapists?

The opportunities

Under the world class commissioning programme, commissioners are judged against three categories: the competencies, outcomes and governance. For clinicians providing services, the outcomes are key. Every commissioner must include a measurement of life expectancy of their population and the level of health inequalities within their area in the 10 outcomes on which they are assessed and reviewed. Each commissioner can then choose up to eight more outcomes to measure depending on the needs of their local population, which must be backed up by quantifiable data. Commissioners need clinicians to improve the outcomes, providing opportunities for physios.

  • PCT provider arms will ‘horizon scan’ to seek out possibilities for service change and improvement
  • physiotherapy input is being sought into strategic change programmes, and aligning PCT priorities with national and SHA plans
  • clinicians are well placed to demonstrate innovation. Proactive and innovative clinicians can ‘help solve commissioners’ problems’
  • cost-effective proposals are likely to be well received by commissioners working with tight budgets

The concerns

  • fragmentation of services: Private firms may cherry pick the most profitable services, leaving the NHS to cope with the most complex and resource-intensive work
  • career paths: with a range of providers in place, will physios’ career progression remain clear?
  • members’ employment: Despite talk of the ‘NHS family’, members’ employment situation will change if they leave direct NHS employment. Rights to stay in the NHS pension scheme will not necessarily carry over, future improvements to NHS terms and conditions will not automatically apply
  • what happens when services are moved out of the NHS and contracts have to be renewed at a future date remains a big question mark
  • will accountability be eroded if NHS care becomes split between a myriad of different providers?
  • are new services, or newly-formed social enterprise providers, clinician-led or driven by employers?

The CSP’s stance

Joby Sessions and Jesse WildThe CSP has always believed that collaboration and communication is the best way to deliver services within the NHS. 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. In a policy statement on Transforming Community Services, agreed earlier this year, CSP Council agreed that any change to organisational structures for community services must be reached after proper consultation with all relevant stakeholders, including 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; and a fully informed and proper consultation with CSP members and their CSP representatives.


Where it has worked: East London

Stephen Wolf/age fotostock/Imagestate Stephen Wolf/age fotostock/Imagestate

Physios working for Tower Hamlets Community Health Services became aware that a new contract to provide a service to tackle adult obesity among the borough’s ethnically diverse communities was being put out to tender by the primary care trust’s public health department. Bids were invited to provide the service at up to four localities within the borough, and the PCT’s musculoskeletal physiotherapy department worked closely with dietitians, psychologists, sports medicine clinicians, and the charity Social Action for Health, to submit a joint bid. The ethos of the proposal was for professional staff to train lay community figures in the charity to provide information and exercise to clients, and for outcome measures to be implemented at the start and the end of the programme. The joint bid was awarded a tender for one of the four sites for one year, with the other contracts going to a variety of providers including private firms. The overall results will be compared between the four providers after one year and then a decision made on further tendering. The Tower Hamlets bid used the high profile of obesity, its model of integrated care and the financial advantages of ill-health prevention to demonstrate its relevance to the commissioners.


Where it has worked: West Essex

It's important that physios appraise themselves of the aims of the PCT. If you are going to suggest a business case that does not fit with the goals of the organisation it is probably going to get short shrift ~ Simon Truett, Head of commissioning for long term conditions, NHS Medway The PCT has pledged staff that their vote will decide whether to establish a social enterprise organisation to provide the PCT’s community services under the Transforming Community Services programme. Although a social enterprise is the PCT’s preferred option, it will only go ahead if 60 per cent of staff back the decision in a ballot. The PCT, which employs around 65 physios, has engaged staff throughout the process, including providing a whole afternoon to debate the plans, with hundreds of staff given the chance to quiz senior PCT management on their proposals through an open microphone question-and-answer session, with input from visiting speakers including from trades unions. The PCT has also involved staff with regular briefing documents, local staff meetings, and regular discussions between management and trades unions. If the PCT’s proposals do not get 60 per cent staff backing, it will look again at other options.

How the CSP can help

The CSP, as part of the Social Partnership Forum, which brings together healthcare unions, NHS Employers and the Department of Health in England, has helped create the new NHS staff passport. By collecting together NHS employment rights and standards in one place, it provides a summary of members’ rights in the event of a transfer and explains how their employment terms and conditions would be affected by a move to any of the range of potential providers. The staff passport is a tool for members but also for commissioners and others to evaluate potential new providers of NHS services. Negotiations to create the staff passport achieved some greater protection for NHS staff. Members transferred to social enterprises will be able to stay in the NHS pension scheme if they continue to work for NHS-funded services. Where members are transferred to social enterprises or the private sector, and continue to work for NHS-funded services, this will count as continuous service if members later return to direct NHS employment. On the ground the CSP provides joined-up advice from professional advisers and senior negotiating officers for members involved in major service re-design or those who may want to campaign for a particular outcome. Useful information can be found on the CSP website and on iCSP networks, and the Society is currently developing a further range of detailed information to help members. This includes a guide to producing a business case, which will help members navigate their way around the commissioning process. The guide and other material is available on the CSP website. The CSP will be running a series of workshops on commissioning in February 2010 in conjunction with The Access Partnership, an NHS-based healthcare consultancy.

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