1. © Nuffield Trust Commissioning for long-term conditions: what do commissioners actually do? Dr Judith Smith Director of Policy, Nuffield Trust The Commissioning Show, Excel, London 12 June 2013

2. © Nuffield Trust Agenda Our study What we found about the practice of commissioning Implications Questions raised

3. © Nuffield Trust 09 October 2015 © Nuffield Trust Our study

4. © Nuffield Trust Overview Aim: To explore the ways in which NHS commissioning can be enacted to assure high quality care for people living with long- term conditions Timescale: Two years (Mar 2010 – Feb 2012) Funding: National Institute for Health Research (NIHR) Health Services and Delivery Research programme

5. © Nuffield Trust Overview (2) Approach Broadly ethnographic, using mixed methods, and with regular feedback to sites Selection of study sites Quantitative metrics summarising 200 indicators used to identify a cohort ‘high performing’ primary care trusts (PCTs) who were invited to take part Data collection Observation of meetings (n=27) Semi-structured interviews (n=124) Informal update interviews (n=20) Analysis of documents (n=345).

6. © Nuffield Trust Three commissioning communities Somerset Calderdale Diabetes StrokeDementia Wirral

7. © Nuffield Trust Commissioning activity being tracked 3 new services which began operating 3 developments being discussed and planned Somerset - Remodelling of diabetes care into a three tier service Wirral – Review of diabetic podiatry to resolve operational problems Somerset – An early supported discharge (ESD) service for patients recovering from a stroke Calderdale – Review of existing provision of diabetes care and discussion of plans for strategic remodelling Wirral - Establishment of a new community-based service for diagnosis and treatment of dementia Calderdale – A strategic review of all dementia care

8. © Nuffield Trust 09 October 2015 © Nuffield Trust What we found out about the practice of commissioning

9. © Nuffield Trust 1The practice of commissioning What we found Something much messier, with much more going on; Process not happening sequentially; Not fitting an annual cycle; Co-ordination and facilitation are big parts of commissioning practice; Support for implementation also a role for commissioners. Assumption A neat cycle of: needs assessment service specification contracting monitoring review

10. © Nuffield Trust 2The labour of commissioning What we found A huge amount of time and effort goes into commissioning; The scale of effort that goes into commissioning may not relate directly to that of the service; Lots of labour is associated with collecting and handling data; Decisions about whether to give priority to a commissioning task may be based partly on the resources available to do the work. Assumption Commissioning is concerned with incentivising other people to do some work

11. © Nuffield Trust 3Identifying the commissioners What we found Multiple and ambiguous roles; Providers often involved in commissioning tasks and events; Commissioners helping to shape, track and undertake implementation; Shared responsibilities across councils and PCTs; Clinicians in many different roles. Assumption Commissioners are people with money to distribute to meet identified needs

12. © Nuffield Trust 4The role of money What we found Money did not seem to be central to a lot of the discussions we observed; Money often appeared late on in the story; The major decisions appeared often to happen in parallel to the ‘nitty- gritty’ of commissioning. Assumption Commissioning decisions will be guided largely by concerns about money

13. © Nuffield Trust 5 The nature of change What we found Change can be very slow to bring about; Commissioners are sensitive about disrupting the local health economy; Change often entails moving staff between organisations; Easier to bring in something new than to decommission; Senior and sustained project management is critical. Assumption Commissioning is a mechanism which allows you to make abrupt and radical changes to service provision (de- commissioning and re- commissioning)

14. © Nuffield Trust 6National ‘guidance’ in a local context What we found Top-down impetus to get things done – this makes a significant difference; A wide range of national strategies and models of what to do; Locally set priorities tend to be within this national context; Savvy commissioners use the national impetus to press ahead with local work. Assumption Local decisions are made by commissioners in response to locally identified needs.

15. © Nuffield Trust 09 October 2015 © Nuffield Trust Implications

16. © Nuffield Trust Implications Commissioning for long-term conditions is made up of multiple and labour-intensive processes Some of these align with the commissioning cycle, others do not – some are conspicuous by their absence; Commissioning practice is less often focused on whole programmes of funding and service provision; It tends to be about more marginal elements of services; Decommissioning rarely features.

17. © Nuffield Trust Implications (2) In commissioning care for people with long-term conditions, the relational aspects tend to dominate Lots of time and effort goes into service design and specification, stakeholder engagement, planning and convening; This work is often critical to bringing about change, but in examples of effective commissioning, there was a recognition of when it was time to ‘get transactional’; Questions for the reformed NHS include whether it can afford so much relational commissioning.

18. © Nuffield Trust Implications (3) The cycle of commissioning lends some order and routine to commissioning It helps commissioners to tie in with the financial planning cycle, contracting, etc.; Long-term conditions are less easily ‘commodified’ than elective services; They may require a different approach to risk-sharing and contracting, with providers incentivised across organisations.

19. © Nuffield Trust Implications (4) There are some critical enablers of commissioning practice Skilled managers, especially at middle-management level – boundary-spanners; Accurate and timely data; A judicious amount of meetings and workshops; Sustained involvement of clinicians; Careful use of national guidance at local level; Clarity about the outcomes expected of commissioning;

20. © Nuffield Trust Questions raised 1.When it comes to the labour of commissioning, how much is too much? 2.To what extent does the blurring of roles challenge the commissioner/provider split? Does this matter? 3.Should money have a more central and specific role in commissioning conversations? 4.Are commissioners held back by caution, or by constraints? Will GP commissioners be more radical?

21. © Nuffield Trust Acknowledgement and disclaimer This project was funded by the National Institute for Health Research Health Services and Delivery Research programme (project number 08/1806/264). The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR HSDR programme or the Department of Health.

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