Some versions of joint commissioning

BMJ 1994; 309 doi: https://doi.org/10.1136/bmj.309.6949.215 (Published 23 July 1994) Cite this as: BMJ 1994;309:215
  1. C Heginbotham
  1. Mr Heginbotham is a senior visiting fellow at the Health Services Management Centre, Birmingham, which is conducting research on joint commissioning for the NHS Executive.

    When the NHS reforms were first implemented in 1991 most emphasis was placed on developing the provider function. Many senior NHS managers opted for operational management, perceiving purchasing as at best uninteresting and at worst trivial and unnecessary. Three years later things look different. The minister of health, Dr Brian Mawhinney, boosted purchasing through a series of three speeches last year,1 and several organisations concerned with health service management now take purchasing seriously.2

    In parallel, some far sighted managers and doctors saw the need to develop purchasing by encouraging collaboration between district health authorities and family health services authorities. These “commissioning agencies” began to offer a more coherent view of what commissioning might achieve by overcoming longstanding bureaucratic boundaries. Some of the first developments were in North West Thames and Wessex regions, where the benefits of joint commissioning were recognised early on, and some authorities, such as the Dorset Commissioning Agency, became a role model for others.3,4

    Nevertheless, joint commissioning has developed slowly. Reasons for this include the continuing independent statutory basis of both district health authorities and family health services authorities and the substantial effort that running two authorities in parallel entails; the challenge of bringing together organisations at different stages of development; and the need to translate a commitment from top managers to those in more junior management positions as well as to general practitioners, particularly fundholders.5 In a recent paper commissioned by North West Thames Regional Health Authority Donald Light has addressed these difficulties in detail.6 He considers locality based joint commissioning as “a movement to overcome the contradictions between needs-based purchasing by district health authorities and fundholding by larger GP practices.” Until last year, the role of general practitioners in commissioning received scant attention except in places such as Hertfordshire that have large numbers of fundholders. With the support of non-fundholding general practitioners some agencies have set up different joint arrangements.

    Light asserts that joint commissioning can overcome the fragmentation inherent in general practice fundholding. He suggests that it is “the most promising aspect of the NHS reforms because it allows an integrated way to commission services in order to maximise the health of everyone in a locality under a single coordinated budget and authority.”6 He cites with approval Scotland and Northern Ireland, where health boards have traditionally managed the responsibilities of both district health authorities and family health services authorities. Unfortunately, it is not true to say that “joint commissioning has been practised for years in Scotland.” Not only was genuine commissioning slower to develop in Scotland and Northern Ireland than in England but the evidence for collaboration is poor. Light also provides examples from other countries - notably the Netherlands, Sweden, the United States, and New Zealand - of how joint commissioning has developed in practice. His examples of American health management organisations as commissioning agencies are unconvincing, although these organisations have in some cases found ways of effectively managing health care for groups as small as 50 000 people. But the lack of effective gatekeepers in primary care in the United States (except possibly in health maintenance organisations that are based on groups of practitioners providing primary and secondary care) has undermined what “combined” commissioning might achieve.6

    Many health commissioning agencies are struggling to bring together the different responsibilities and cultures of district health authorities and family health services authorities. To be effective, as Light shows, they will now have to develop workable mechanisms for involving general practice fundholders, even though many managers find that irksome.6 Light suggests that, when fundholders are involved, moving from managed competition to managed coordination is possible.6 He proposes that the NHS needs to forge a coherent vision and to disentangle the organisational and fiscal contradictions that continue to reduce value for money.

    So far, so good. Unfortunately, an entirely separate Department of Health project group also uses the term “joint commissioning.” This refers to arrangements between health authorities and local authorities jointly to commission community health and social care. Following a speech by Dr Mawhinney two years ago in which he said that “joint commissioning … is a question of sharing responsibilities … in pursuit of a common goal of better services for users and carers …” the Department of Health issued guidance in March last year.7 Together with a paper by Knapp and Wistow,8 this set the scene for joint commissioning of community care. Five pilot areas for commissioning services for elderly people were identified and are now operating: Oxfordshire, Hillingdon, Easington, Westminster, and Wiltshire. In each area primary health care teams have been actively involved. Key concerns that have emerged include the definition of locality, how much power should be devolved to local commissioning teams, who should serve as the locality commissioners, the relations between the strategic planning role of health authorities and the operational role of general practitioners, linkages with statutory agencies, and clarification of decision making.9

    The objectives of the joint commissioning project group are to achieve a seamless service, to help avoid arguments about who is responsible for running services, and to avoid cost shunting. The group also aims to improve cost effectiveness, to ensure that assessment of need is unhindered by organisational boundaries, and to promote innovation. Such objectives could usefully be set for the locality joint commissioning described by Light. A further twist has been given to this debate by Wandsworth Borough Council's proposal that it should take over the commissioning of health care. Although this has met with a lukewarm response from ministers, it accords with both the present government's agenda for joint commissioning and suggestions from the Labour party for greater local democratic control of health authorities. Joint commissioning may be the route to another far reaching reorganisation.

    Good relations between commissioning agencies and fundholders will be essential to achieve the greatest health gain for the population while meeting patients' expectations. As Ham suggests, however, concerns exist about the effort involved in managing budgets and “the ability of enthusiasts in fundholding practices to sustain the workload they have taken on in recent years.”

    If there is to be genuinely seamless care, particularly for people with chronic disorders, then the further step of involving local authorities' social services departments in commissioning will be essential. Westminster City Council has taken one step in this direction by commissioning community support and rehabilitation services from an NHS trust. The opportunity for seamlessness is available if health commissioning agencies, general practitioners (both fundholding and non-fundholding), and social services departments work closely together. But much organisational development is needed to clarify roles and responsibilities, to simplify and streamline systems, and to ensure that the patients themselves are given a genuine voice in commissioning care.10


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