Just because commissioning doesn't work doesn't mean you should abolish it
Many of Maynard's criticisms of commissioning in the English NHS are correct. But there are two reasons why that doesn't imply we should abolish it.
First: are there any benefits? The evidence for the effectiveness of provider competition (a major theoretical justification for commissioning) exists, but is weak. Though this is perhaps unsurprising given the way commissioning has been designed. So Maynard is right to say the experiment doesn't look like a great success.
But the first compelling reason why this doesn't imply the need for another major reorganisation is that such a reorganisation would certainly incur significant costs and disruption. But the benefits of abolition (like the benefits of provider competition) are uncertain. Anti-market campaigners have often quoted very large numbers for the potential savings of abolishing the internal market but these are implausible and not apparent in other places that have reverted to the older structures. Plausible estimates of savings, if they exist at all, are very unlikely to compensate the NHS for another few years of systemic disruption.
But one of the reasons why the savings from abolishing the market are likely to be small is also one of the reasons why the system doesn't work well now. Maynard correctly identifies that good commissioning decisions require good information. But the system is fragmented and much of the information is not accessible. I would add that the system has been starved of the management capacity to process that information (the NHS is undermanaged by any reasonable benchmark and when it comes to information the system exists on starvation levels of capability and capacity). It is little wonder that CCGs can't make better decisions: they mostly lack either the information or the capacity to make sense of it. abolishing them wouldn't help, though. Someone still has to make planning decisions and allocate the resources to the most useful ends. And abolishing the purchaser provider split would not magically create more capacity to make good decisions. So we would get more disruption but no tangible benefit.
A better approach would be to acknowledge why experiments like commissioning have not worked well. It's about information. If we are going to do a better job of decisions in the NHS (however we choose to organise the system) we need good reliable information about what is going on and what the outcomes of treatment are. The current NHS is woefully deficient in good information: it isn't organised to collect it effectively; it lacks the capacity to process it quickly; and it is starved of the capability and capacity to derive useful insights from the information it has. Information skills are pushed down the priority list every time a politician says "more resources to the front line" despite the fact that we won't allocate those resources to the right parts of the front line if we don't have good information about where they are needed.
However the NHS is organised, it can't do a better job without good information. We'd be far better investing a little in that before we tear up the structure again.
Rapid Response:
Just because commissioning doesn't work doesn't mean you should abolish it
Many of Maynard's criticisms of commissioning in the English NHS are correct. But there are two reasons why that doesn't imply we should abolish it.
First: are there any benefits? The evidence for the effectiveness of provider competition (a major theoretical justification for commissioning) exists, but is weak. Though this is perhaps unsurprising given the way commissioning has been designed. So Maynard is right to say the experiment doesn't look like a great success.
But the first compelling reason why this doesn't imply the need for another major reorganisation is that such a reorganisation would certainly incur significant costs and disruption. But the benefits of abolition (like the benefits of provider competition) are uncertain. Anti-market campaigners have often quoted very large numbers for the potential savings of abolishing the internal market but these are implausible and not apparent in other places that have reverted to the older structures. Plausible estimates of savings, if they exist at all, are very unlikely to compensate the NHS for another few years of systemic disruption.
But one of the reasons why the savings from abolishing the market are likely to be small is also one of the reasons why the system doesn't work well now. Maynard correctly identifies that good commissioning decisions require good information. But the system is fragmented and much of the information is not accessible. I would add that the system has been starved of the management capacity to process that information (the NHS is undermanaged by any reasonable benchmark and when it comes to information the system exists on starvation levels of capability and capacity). It is little wonder that CCGs can't make better decisions: they mostly lack either the information or the capacity to make sense of it. abolishing them wouldn't help, though. Someone still has to make planning decisions and allocate the resources to the most useful ends. And abolishing the purchaser provider split would not magically create more capacity to make good decisions. So we would get more disruption but no tangible benefit.
A better approach would be to acknowledge why experiments like commissioning have not worked well. It's about information. If we are going to do a better job of decisions in the NHS (however we choose to organise the system) we need good reliable information about what is going on and what the outcomes of treatment are. The current NHS is woefully deficient in good information: it isn't organised to collect it effectively; it lacks the capacity to process it quickly; and it is starved of the capability and capacity to derive useful insights from the information it has. Information skills are pushed down the priority list every time a politician says "more resources to the front line" despite the fact that we won't allocate those resources to the right parts of the front line if we don't have good information about where they are needed.
However the NHS is organised, it can't do a better job without good information. We'd be far better investing a little in that before we tear up the structure again.
Competing interests: No competing interests