1) The study explored how NHS commissioning can assure high quality care for people with long-term conditions through ethnographic research in three commissioning communities over two years. 2) The research found that commissioning in practice is messier than assumed, involves coordination and facilitation beyond a neat annual cycle, and commissioners play roles in implementation support. 3) The implications are that commissioning long-term conditions requires extensive relational work that may not align with the commissioning cycle and that there are critical enablers like skilled managers and clinicians that support effective commissioning practices.

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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

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Agenda
• Our study
• What we found about the practice of commissioning
• Implications
• Questions raised

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Our study

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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

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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).

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Three commissioning communities
Somerset Calderdale
Diabetes
Stroke Dementia
Wirral

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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

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What we found out about the
practice of commissioning

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1 The 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

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2 The 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

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3 Identifying 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

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4 The 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

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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)

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6 National ‘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.

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Implications

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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.

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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.

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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.

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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;

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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?

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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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