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NHS Commissioning explained…

What is commissioning?

At its most basic level, commissioning is the process of planning, agreeing, buying and monitoring healthcare provision in order to meet the needs of patients in England. This involves commissioning or developing services within the internal NHS market and also buying in services from private providers.

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Who is responsible for commissioning what in the current system?

At present, there are a number of different organisations that are responsible for commissioning services across the NHS for England’s population. With a budget of £69.2 billion, Clinical Commissioning Groups (CCGs) have the largest share of the total NHS budget of £116.4 billion and are responsible for commissioning a wide range of services relating to public health, mental health, and community and hospital services. From 2015/16 onwards, a majority of CCGs have also assumed responsibility for all aspects of primary care commissioning. Led by General Practitioners, and supported by a range of other healthcare professionals, there are 209 CCGs in England that work closely with a range of public and private bodies, including local authorities and the voluntary sector, to plan, commission and deliver services. This includes a wide range of services, from emergency and urgent care through to infertility services and maternity and newborn provision.

NHS England is responsible for making sure that all NHS organisations discharge their commissioning responsibilities appropriately, and also work closely with CCGs and a range of other providers on specialist commissioning services. Whereas CCGs will typically commission services for a clearly defined local geographical area and population, specialist services often cover large regional or national networks due to only being required by a small section of the overall population. At present specialist commissioning includes a number of different areas such as the provision of all aspects of care and laboratory testing facilities that relate to haemophilia. Specialist commissioners in areas such as haemophilia also work closely with other specialist areas such as genetic services, and they are advised by Clinical Reference Groups (CRGs) who provide specific clinical guidance and expertise on the best way in which services should be structured and delivered. CRGs are comprised of clinicians, commissioners, public health experts and patients.

NHS England, working closely with Public Health England, is also responsible for the commissioning of all screening and immunisation services within England, with a total budget of 1.8 billion. NHS England also has commissioning responsibility of a number of highly specialised public health services, working closely with a wide range of other commissioning organisations to cover areas such as tuberculosis control, dental screening and oral health improvement. It also has oversight of the Cancer Drugs Fund which was established in 2013 to provide additional funding for cancer medication that is not routinely available on the NHS for all patients. The fund also provides additional capital for standard operating procedures and allows cancer specialists to make individual requests for specialist treatment for rarer types of cancer, including those affecting children.

What is the commissioning cycle?

The commissioning cycle refers to the stages involved in planning healthcare services for a defined population. Fundamentally, the process can be broken down into four separate stages: analysing and planning (finding out the healthcare needs of the local population and mapping out a process for meeting them), designing pathways (organisation the healthcare system in a way that patients have timely, equitable access to services), specifying and procuring (being clear about exactly what is required and purchasing it from either internal or external providers), and delivering and improving (an ongoing process of monitoring and evaluation to ensure that services meet the needs of the population they serve). As the healthcare needs of the population are always changing, and medical technologies continue to evolve, the commissioning cycle is an ongoing process that constantly requires revisiting and updating.

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Source: NHS Library Services

The commissioning cycle also links into the procurement of services, where commissioners will work directly with procurement teams within the NHS to identify potential contractors who may wish to tender for contracts that are made available. Procurement and commissioning teams will often work closely together on market testing events (or soft market testing) to explore options around which providers are interested and/or suitable for delivering a particular service.

Is commissioning the same as purchasing or contract management?

Commissioning is different from purchasing and contract management, which typically relates to information and materials management and internal logistics within the NHS (such as distribution, the bulk purchasing of medical supplies, or the movement of stores). Many commissioning arrangements will have some aspect of contract management involved, although this isn’t always undertaken by the individual or organisation responsible for commissioning a particular service.

How have commissioning arrangements changed in recent years?

The Health and Social Care Act, introduced by the last coalition government, resulted in a number of significant changes in regard to the structure of the health service and its commissioning responsibilities. CCGs replaced 152 Primary Care Trusts (PCTs) who had previously held responsibility for a wide range of commissioned services, and some responsibilities moved to other organisations. Public health teams, now based in local government, have statutory responsibility for the commissioning of the NHS Health checks programme, the National Child Measurement Programme, sexual health services, and drug and alcohol misuse services.

A number of different factors have also resulted in new commissioning arrangements being developed in England. The NHS efficiency savings target, set by the government at £22bn over the course of the current parliament, has forced many commissioning organisations to reconsider how they organise the way in which services are bought and delivered. Further financial cuts to social care and public health budgets in local authorities are also forecasted to place considerable strain on NHS services and the overall healthcare system, and in response to this many CCGs and local authorities are looking to integrate their commissioning responsibilities in order to provide a more responsive, joined-up response to local health and social care needs. More recently, a number of ‘vanguard’ sites have been identified that will explore new commissioning and delivery arrangements around a number of NHS priorities including integrating primary and acute care systems and urgent and emergency care vanguards. It is hoped that exploring new ways of working, and the joint commissioning of services, will improve the clinical and financial viability of healthcare provision in these areas.

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