Report calls for National Commissioning Board to have strategic commissioning role

BMJ 2011; 342 doi: (Published 03 March 2011) Cite this as: BMJ 2011;342:d1355
  1. Jacqui Wise
  1. 1London

The Health and Social Care Bill should be amended to give the National Commissioning Board statutory responsibility for strategic commissioning, argues a new report for the King’s Fund.

The report says there is a need for strong strategic commissioning to reconfigure services such as cancer, cardiac, stroke, and renal services across large geographical areas. The report says GP led consortiums are unlikely to fill the gap once strategic health authorities are abolished and that the new National Commissioning Board should be given the statutory powers and the capability to perform this role effectively.

Keith Palmer, former chair of Barts and the London NHS trust and a senior associate at the Nuffield Trust, carried out a detailed analysis of the reconfiguration of acute hospital services in southeast London and highlights the lessons that can be learnt for the rest of the country.

He argues that with the NHS needing to find up to £20bn (€23bn; $32bn) in productivity improvements over the next few years major changes to the provision of hospital services are urgent and essential. But he says market forces alone are unlikely to improve the provision of hospital services and only strong commissioning can improve quality and drive down costs.

In southeast London where there has been a major and protracted reconfiguration exercise, Mr Palmer said primary care trusts were unwilling or unable to tackle the challenges facing acute hospitals and only when the strategic health authority became involved was some progress made. “Without strong strategic commissioning driving reconfiguration everything got in a terrible mess,” he told the BMJ.

He said: “A great deal of the emphasis of the government reforms is in letting the market operate but the evidence we have from south London is that this improves quality in a few ‘winners’ but not in the remaining ‘losers.’”

The four district general hospitals in southeast London had faced chronic financial and quality issues for a number of years. Under the reconfiguration process, which was finally signed off in December 2010, Queen Mary’s, Sidcup will no longer take emergency admissions and instead become a central hub to provide local community hospital services. The emergency department, obstetrics, and paediatrics will be consolidated at the neighbouring Queen Elizabeth hospital, Woolwich; University Hospital, Lewisham, and Bromley Hospitals Trust.

Hospital reconfigurations will be driven over the next few years by the requirement for all NHS trusts to achieve foundation trust status by 2014. There are around 70 hospital trusts which have so far failed to achieve the financial performance and quality of care required for them to become foundation trusts. A substantial number of these have large debts and private finance initiative commitments.

The report argues that neither high performing foundation trusts nor private sector providers will want to take on such financially challenged trusts without support. It calls for changes to the way hospitals are funded so that the tariff reflects differences in fixed capital costs, rather than paying the average capital costs of all hospitals as at present. This would increase funding for hospitals with large PFI debts at no net cost to the NHS.

Mr Palmer told the BMJ: “I think it’s impossible for all NHS trusts to be FTs [foundation trusts] by 2014 in the current configuration. There will need to be mergers—which in fact will be takeovers. And this will only happen if the government intervenes in some way.”

The report recommends that the Department of Health supports acquisitions of hospitals in financial difficulty by high performing trusts. Although this may reduce competition it is the most effective way to improve quality for patients, the report argues. Mr Palmer told the BMJ that the Health and Social Care Bill needs to be amended to ensure that Monitor has responsibility not just to promote competition but to weigh up the benefits of such mergers.


Cite this as: BMJ 2011;342:d1355