BMA principles for effective and successful commissioning


November 2006 The BMA views the commissioning of patient care as a key function of a National Health Service seeking to balance the clinical needs of patients with the finite resources that society is prepared to make available via general taxation. Most importantly, effective commissioning has the potential to improve the range and quality of health services available to patients.

This document outlines a series of principles which the BMA would wish to see upheld as the role of commissioning develops.

Promoting clinical engagement and creating the right environment
Engendering meaningful clinical engagement from and with both primary and secondary care is central to successful commissioning. In particular, increased attention should be paid to engagement with clinicians in secondary care and public health and more careful consideration paid to existing engagement with clinicians in primary care.

There are a number of ways to encourage clinical engagement, but these are quickly and easily overshadowed by the numerous disincentives which discourage involvement. For example, reducing commissioning to a demand management or ‘rationing’ mechanism acts as a major disincentive to primary care clinicians from becoming involved in the process, as does stifling innovation. Using negative incentives to drive engagement of secondary care, such as fear of destabilisation, is both inappropriate and ineffectual. Another major disincentive for both sectors arises from targets being set, whether local or national, which are unachievable and/or unrealistic. In order to promote clinical engagement, the terms of involvement should be fair, reasonable and equitable, an adequate resource should be made available to support the work involved and where there is a need for clinicians to develop particular skills, this should be identified and addressed.

The landscape of national policy heavily influences the cultural environment within which commissioning takes place. Effective commissioning is central to the Government’s current reform programme, other key aspects of which include patient choice, plurality of providers, contestability, moving care closer to home and payment by results. Within this programme of reform there is inherent conflict and the BMA would wish to see a reappraisal of Government policy which results in the establishment of a coherent and shared vision. Commissioning cannot be viewed out of context and in order to succeed, both within the current financial climate and amidst all other change underway in the NHS, it must be properly supported as outlined above.

Enabling cross-sector collaboration
As clinical engagement does not only apply to GPs and primary care clinicians, the BMA wishes to see the establishment of effective and meaningful clinical networks across both primary and secondary care and public health. Public health doctors offer an invaluable role in supporting good quality commissioning. Their input includes needs assessment, critical appraisal of the published evidence, clinical effectiveness, priority setting, developing service models and service specifications, setting service standards, monitoring clinical outcomes, and service review and evaluation. Public health input into commissioning will make it possible to determine the optimum affordable basket of health care. Only through a collaborative approach, together with an intimate knowledge of both local and national health priorities, can commissioning be effective and produce patient-centred outcomes.

A number of the current reforms have the potential to erode relations between the primary and secondary care sector. Payment by Results in particular creates a tension between primary care commissioners, who are encouraged to refer less, and those in secondary care, who are incentivised through the national tariff to carry out more procedures in hospitals. This sets up a potential clash that discourages the collaboration that is needed to develop co-ordinated services and deliver best care for patients. Consequently, there is an urgent need to reform Payment by Results, including refining and unbundling the tariffs. In addition, effective collaboration will only be achieved where there is promotion of and support for clinicians across all sectors of healthcare to work together and the BMA wishes to see incentives in place for such cooperation to be achieved.

Ensuring an appropriate balance between cost-effectiveness, quality and long-term sustainability of the health economy
The current emphasis on commissioning to achieve immediate and short-term financial aims needs to be rebalanced to give equal importance to commissioning to achieve high quality patient services and long-term sustainability of the health economy. Financial balance, whilst important, must be achieved over a timescale that allows the continued delivery of real clinical need whilst the process of more effective and efficient re-provision of services takes place. Ill-thought-out, unsupported and short-term commissioning changes whose prime function is simply to reduce costs are likely to result in long-term problems and not ultimately achieve financial stability.

Commissioning decisions, whatever the level/scope, need to be considered within the wider context of the local NHS economy and should consider the implications of service redesign such as destabilisation of existing services and/or a depletion in the opportunities available for education and training.

Effective dialogue with patients and the public
The BMA believes that patient care should be at the heart of commissioning yet there is little confidence left among patients and the public in terms of their views being heard, both at a national and local level. There must be an open and honest debate with the public so that they are intimately involved in the development of commissioning decisions, feel that their needs and choices are being fully recognised and have realistic expectations of the services that can be delivered within finite resources. Rather than an adversarial approach, the fullest and widest possible public and patient participation in collaborative decision-making should be encouraged.

Development of information systems
In order to support commissioning, data must be accurate, timely, quality-checked and validated. This area needs urgent attention and investment to enable robust commissioning, to inform service redesign and to monitor the effects of any service changes put in place. There is a joint benefit in ensuring accurate data upon which to base commissioning decisions and planning which relies heavily on engagement and collaboration with secondary care.

The future of commissioning
In addition to patient care, the BMA believes that the overarching ethos and ethics of a publicly provided health service should also be at the heart of commissioning. Enabling non-NHS, commercialised, private companies to be heavily involved in commissioning has the potential to put these fundamental principles at risk. Where commercial gain takes priority over regard for the patient experience, the process of commissioning will inevitably be compromised. We would therefore wish to see commissioning remain a core function of the National Health Service and call for the appropriate support to be given to clinicians in order to enable them to succeed in the commissioning role.

© British Medical Association 2008

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