{"id":36123,"date":"2016-02-05T10:32:47","date_gmt":"2016-02-05T09:32:47","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=36123"},"modified":"2016-02-05T10:32:47","modified_gmt":"2016-02-05T09:32:47","slug":"richard-smith-commissioning-needs-to-be-about-all-public-services-not-just-health","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2016\/02\/05\/richard-smith-commissioning-needs-to-be-about-all-public-services-not-just-health\/","title":{"rendered":"Richard Smith: Commissioning needs to be about all public services not just health"},"content":{"rendered":"

\"richard_smith_2014\"<\/a>Parliament has three times relegislated the commissioner provider split\u2014in 1990, 2002, and 2012, said Stephen Dorrell, secretary of state for health from 1995-97, in a talk to the Imperial College Centre for Health Policy this week. Every health secretary for the past 26 years\u2014with the exception of Frank Dobson\u2014has believed in commissioning. But, he asked, how does it work, how should it work, and how might it work in the future?<\/p>\n

The concept, Dorrell said, is simple: the commissioners should start not with existing institutions and ways of doing things but with the needs of individual citizens. They should then set priorities and find the best way to meet those needs paying attention to quality and value for money. They should be open minded and not bound to existing providers. Commissioning, argued Dorrell, provides our best chance of reshaping the care system, which we badly need to do and have so far failed to do.<\/p>\n

Commissioning empowers local authorities who better know the needs of local people than the centre and who if genuinely empowered will do a better job than central planners. The alternative to commissioning is central planning, and, said Dorrell, one of the big lessons of the 20th century is that central planning does not work. Yet when the NHS is funded from income tax there must be a means to hold local authorities to account, and commissioning provides that means.<\/p>\n

So commissioning works in theory and is such an attractive concept that all secretaries of state for health (bar one) for the past 26 years have opted for it. But does it work in practice?<\/p>\n

Dorrell articulated that question and its sister \u201cDoes competition work?\u201d He acknowledged that many people have analysed the evidence to give different answers but didn\u2019t attempt to summarise the evidence. But he did say that competition is not a choice but a fact of life. He was, he said, competing as he spoke, putting forward an argument when others would have a competing argument. There is always competition of ideas and for resources and attention.<\/p>\n

In effect, however, he accepted that commissioning in the NHS has failed\u2014it has been too process driven, too dominated by lawyers, and hasn\u2019t delivered the system change that\u2019s needed. But he was convinced that we should not go back to central planning, which means the system doing the best it can and explaining why that\u2019s all that can be done. The \u201cfatal flaw\u201d in the system, he claimed, was that the commissioning was for the NHS (the \u201cNational Sickness System\u201d) rather than for the totality of care. Those who commission care for elderly people should, for example, be able to commission social care and social housing, so avoiding unnecessary admissions to hospital. Those commissioning children\u2019s services should be linked to schools and the criminal justice system\u2014and so able to break the cycle that leads to truanting, drug addiction, prison, and alcoholism. The children who fall into this terrible trap cost public services a fortune but receive little benefit.<\/p>\n

The \u201cfatal flaw\u201d has been recognised, and one result is to give the city of Manchester its NHS resources and allow local authorities to commission from all public services (which Dorrell defines as service for the public rather than services owned by the public).<\/p>\n

Dorrell outlined five conditions that should allow commissioning to work properly: commissioners should:<\/p>\n