Designing whole-systems commissioning: lessons from the English experience

The paucity of formal evidence, allied to the requirement for strategies that are sensitive to local history and context, means that a ‘blueprint’ for successful strategic commissioning is not currently available for adoption. We are therefore confined to proposing ‘design principles’ for those seeking to embark upon a transition towards a whole systems approach to strategic commissioning. People and relationships are of critical importance all the way through the chain from strategic commissioning to micro-commissioning. Most crucially, experience suggests that structural solutions alone cannot deliver effective relationships and will not be effective when relationships are neglected. The need to ensure staff, partner and political buy-in suggests that relationship management and consensus-building are an integral component of the leadership role in moving toward strategic commissioning. As with any major re-organisation, the move to strategic commissioning is essentially a change management initiative and therefore will stand or fall according to whether it adheres to good practice in the change management process. Central to this, and to achieving commissioning outcomes, is the requirement for meaningful service user and public engagement. Effective commissioning emphasizes individual capabilities as well as needs, and community assets as well as deficits and problems. Adoption of strategic commissioning approaches is still at the developmental and learning stage and arguably all structural arrangements should be regarded as transitional

Prospects for progress on health inequalities in England in the post-primary care trust era : professional views on challenges, risks and opportunities

Background - Addressing health inequalities remains a prominent policy objective of the current UK government, but current NHS reforms involve a significant shift in roles and responsibilities. Clinicians are now placed at the heart of healthcare commissioning through which significant inequalities in access, uptake and impact of healthcare services must be addressed. Questions arise as to whether these new arrangements will help or hinder progress on health inequalities. This paper explores the perspectives of experienced healthcare professionals working within the commissioning arena; many of whom are likely to remain key actors in this unfolding scenario. Methods - Semi-structured interviews were conducted with 42 professionals involved with health and social care commissioning at national and local levels. These included representatives from the Department of Health, Primary Care Trusts, Strategic Health Authorities, Local Authorities, and third sector organisations. Results - In general, respondents lamented the lack of progress on health inequalities during the PCT commissioning era, where strong policy had not resulted in measurable improvements. However, there was concern that GP-led commissioning will fare little better, particularly in a time of reduced spending. Specific concerns centred on: reduced commitment to a health inequalities agenda; inadequate skills and loss of expertise; and weakened partnership working and engagement. There were more mixed opinions as to whether GP commissioners would be better able than their predecessors to challenge large provider trusts and shift spend towards prevention and early intervention, and whether GPs’ clinical experience would support commissioning action on inequalities. Though largely pessimistic, respondents highlighted some opportunities, including the potential for greater accountability of healthcare commissioners to the public and more influential needs assessments via emergent Health & Wellbeing Boards. Conclusions - There is doubt about the ability of GP commissioners to take clearer action on health inequalities than PCTs have historically achieved. Key actors expect the contribution from commissioning to address health inequalities to become even more piecemeal in the new arrangements, as it will be dependent upon the interest and agency of particular individuals within the new commissioning groups to engage and influence a wider range of stakeholders.</p

Commissioning strategies and methods

Accelerator beam commissioning is a challenging and exciting period. It is generally the first integrated operation of the many systems in an accelerator and, most importantly, of the beam. First, general preparation is discussed. Then general methods for initial beam commissioning are described, including methods for transverse and longitudinal beam set-up. The particular emphasis here is on tuning methods for linear accelerators.Comment: 16 pages, contribution to the CAS - CERN Accelerator School: Course on High Power Hadron Machines; 24 May - 2 Jun 2011, Bilbao, Spai

Views of NHS commissioners on commissioning support provision. Evidence from a qualitative study examining the early development of clinical commissioning groups in England

Objective: The 2010 healthcare reform in England introduced primary care-led commissioning in the National Health Service (NHS) by establishing clinical commissioning groups (CCGs). A key factor for the success of the reform is the provision of excellent commissioning support services to CCGs. The Government's aim is to create a vibrant market of competing providers of such services (from both for-profit and not-for-profit sectors). Until this market develops, however, commissioning support units (CSUs) have been created from which CCGs are buying commissioning support functions. This study explored the attitudes of CCGs towards outsourcing commissioning support functions during the initial stage of the reform. Design: The research took place between September 2011 and June 2012. We used a case study research design in eight CCGs, conducting in-depth interviews, observation of meetings and analysis of policy documents. Setting/participants: We conducted 96 interviews and observed 146 meetings (a total of approximately 439 h). Results: Many CCGs were reluctant to outsource core commissioning support functions (such as contracting) for fear of losing local knowledge and trusted relationships. Others were disappointed by the absence of choice and saw CSUs as monopolies and a recreation of the abolished PCTs. Many expressed doubts about the expectation that outsourcing of commissioning support functions will result in lower administrative costs. Conclusions: Given the nature of healthcare commissioning, outsourcing vital commissioning support functions may not be the preferred option of CCGs. Considerations of high transaction costs, and the risk of fragmentation of services and loss of trusted relationships involved in short-term contracting, may lead most CCGs to decide to form long-term partnerships with commissioning support suppliers in the future. This option, however, limits competition by creating ‘network closure’ and calls into question the Government's intention to create a vibrant market of commissioning support provision