'Commissioning a patient-led NHS' letter and response

In July 2005, Sir Nigel Crisp, Chief Executive of the NHS, wrote to all primary care trusts (PCTs), NHS bodies and local authorities to set out plans to develop commissioning. This circular built on plans outlined in the NHS improvement plan and Creating a patient-led NHS.

Crisp noted that the NHS was moving from a provider-driven service to a commissioning-driven one and that the role of PCTs in the provision of services was expected to become minimal by the end of 2008. The concept was not new, as previous secretaries of state had accepted that the quality of what was purchased was more important than who purchased it.

Continuing concern that commissioning was ineffective, compared with the competence of providers in negotiations, led to several programmes to develop commissioning in the NHS and to reconfigure PCTs.

Development of commissioning

The development of commissioning would have two stages. Firstly, strategic health authorities (SHAs) would lead a review into the configuration of commissioning organisations. Secondly, there would be a process established to enhance the ability of SHAs, PCTs and individual practices to undertake their functions effectively.

Services should be procured from a range of providers, contributing to patient choice.

The document also set out its expectation that PCTs should have made arrangements for complete coverage of practice-based commissioning by December 2006, but this initiative didn't really take off.

Health Committee inquiry

In January 2006, in response to Commissioning a patient-led NHS, the House of Commons Health Committee launched an inquiry to assess the proposed restructuring of PCTs.

The committee felt that PCTs had not been given enough time to develop and was concerned that PCTs might be required to divest themselves of their service delivery functions and, in parallel, the introduction of practice-based commissioning would make the commissioning role of PCTs redundant.

Additionally, there was a fear that alternative providers might not be available to pick up the provision of services.

The committee noted the reconfigured PCTs would be similar in size to the former health authorities that had been deemed ineffective and isolated from patients: 'despite the considerable attention these proposals have attracted in parliament and elsewhere, debate has focused almost exclusively on the shape of future organisations, the morale of staff, and the consultation process, largely ignoring the critical issue of how commissioning can actually be improved'.

Government response

In March 2006, the government responded to the Health Committee's critical report. Although the government noted the committee's concerns that PCTs should have been allowed to evolve, it felt that not all PCTs would have benefited from this approach.

The government felt that the Health Committee's concerns about the destabilising effect of reconfiguration were unfounded:
‘While restructuring can be disruptive, this is not change for change's sake. This change is necessary to equip the NHS to deliver the next stage of the reform programme. The NHS has been telling us for some time that structural change is necessary and Commissioning a patient-led NHS is a response to that - it is not a return to the old health authorities.’

The report stated that the commissioning capacity of PCTs would be strengthened by the reforms, and patients would ultimately benefit. It further asserted that PCTs could not stay static in form and function and needed to change and adapt.

In response to the committee's concerns around PBC, the government argued that it would allow primary care professionals to reduce hospital admissions and be better equipped to manage care pathways for patients. PCTs would still have a role in supporting and managing PBC groups, by agreeing budgets with practices, negotiating and managing contracts and making sure that budgets were being spent appropriately.

The government made it clear that PCTs would still be able to provide services. Where PCTs continued to provide services, they would be expected to ensure they had clear governance arrangements established to monitor any conflicts of interest between their commissioning and provider functions. The document asserted that the government would not instruct PCTs to give up their provider functions, but would support those who wished to.