I joined the NHS in the early 1990s as a management trainee, when commissioning was in its infancy. The theory was simple: independent local bodies, set apart from the interests of professionals and hospitals, would assess the needs of a population, hold the budget and “purchase” services from providers.
Yet 25 years later, some of the challenges associated with this approach are more apparent. Services need to innovate, make a better job of joining up care around people and act more rapidly on the insights they gain from users, while managing within ever tighter budgets.
Often, service providers are best placed to lead such changes. This means we may be entering a period in which the split of responsibilities between those who purchase healthcare and those who provide it changes significantly. The consequences for how politicians and the public hold services to account could be far reaching.
Simon Stevens’s NHS Five Year Forward View sets out a vision of new, integrated models of care. Multispecialty community providers (MCPs) are designed to unite GPs, services such as community nursing, and outpatient procedures like diagnostics and minor surgery. Primary and acute care systems will bring hospitals, GPs and community health services together into a single body. Over time, many responsibilities for developing new services, the health of a population and their associated budgets are expected to pass from commissioners to these new bodies. In effect, they may reunite many of the “purchaser” and “provider” roles.
These approaches are being piloted by the NHS in 13 areas across England. This reflects a pattern across the public sector. Schools are responsible for the vast majority of education budgets, deciding how to use these and when to draw in specialist services. The detail of planning employment services, and more recently probation services, is now primarily in the hands of large “prime providers”.
My instinct is that these models are here to stay. So I argue, in a paper included in the Nuffield Trust’s publication Reconsidering accountability in an age of integrated care, that we must reconsider important elements of the governance and accountability system for health and care: a system that has rested primarily on commissioning.
The first question is whether the way in which integrated providers are governed needs to be strengthened as they take on more responsibility and power. For example, many MCPs are likely to form by bringing together privately owned GP partnerships. Yet strong, autonomous new models of provision in many sectors, such as free schools and independent social worker practices, have to be governed for a social purpose without the scope for making a profit. In sectors where they are allowed, such as probation, commercial providers have quickly come to dominate. Before too many precedents are set for integrated care, we need a debate on the best forms of ownership and governance.
Regulators also need to consider how they evolve. Integrated provision could allow regulators to focus on how to hold providers to account and ensure local services work together to support patients in the round. But this will require investing in systems to make it easier to identify and measure outcomes, and a tricky balance of enabling innovation while also recognising that independent inspection and regulation become even more important as providers take on more responsibility.
Finally, local authorities and clinical commissioning groups need to consider how they can best represent the voice of residents. One approach could be to merge to develop strategic commissioning at a city, region or county level, shifting from planning the detail of local services to overseeing the health and care system as a whole, as Greater Manchester and Cornwall are exploring.
As clinicians, managers and our political representatives develop and explore these new models, doing so without another long, controversial NHS bill in parliament brings many advantages.
But the absence of legislation should not be an excuse to avoid the questions thrown up by these changes. As new organisations bring together more and more elements of the NHS, we have a duty to keep the health service accountable to patients and local people.
