The role of ICBs is up for debate. The talk now is of ICBs as strategic commissioners, but the danger is that this is seen simply as a downgrading of their role but this would be to underestimate the vital importance that commissioning can and should play.
The concept of commissioning was only introduced into the NHS in the early 1990s, when then Conservative health secretary Kenneth Clarke split the purchasers of care from the providers. Clarke argued that making providers compete for resources would encourage a more efficient NHS to form, driving a new era of choice and competition.
Since then, every reform of the health service's commissioning bodies has led to thousands of column inches often hailing ‘the end of the purchaser-provider split'. Despite key aspects of Sir Andrew Lansley's 2012 reforms, over the past 25 years the NHS has moved further and further from competition and towards collaboration. This led some to predict the death of commissioning and a rapid evolution towards accountable care organisations, yet commissioners have remained.
We could in principle return to the type of NHS we had before the 1989 reforms, but it is unlikely that any new secretary of state for health and social care would attempt to up-end the NHS by returning us to the days of regional health authorities and entirely state-owned services. But the continued presence of local commissioners is less as a reflection of political nervousness and more of the value that they add to the system.
The NHS is a complex and ever-growing ecosystem and there is clearly a need for some sort of planning function that ensures its £205bn budget is used effectively. This is the core purpose of commissioners: to get the best possible outcomes for their populations from the fixed pot of money they receive. I have consistently seen commissioners – even when under extraordinary pressure to cut costs – try their hardest to get the best outcomes for those they serve.
While the centre has a key role in ensuring consistency across the country, few would argue that it has the local knowledge or relationships to design services to meet the needs of individual places. Some of the most compelling ICB examples of innovation in the last few years have focused on reducing health inequalities, where they have allocated their resources in new ways to address the needs of their particular populations. Commissioners also have a crucial role looking beyond the NHS. Holders of the public purse need to be able to commission services from the organisations best placed to provide them. Commissioners must sit close enough to providers to understand the landscape they operate in but far enough away to look beyond individual priorities. They also need a degree of autonomy to look beyond the NHS borders towards the more diverse world of private providers, local authorities and voluntary, community and social enterprise organisations that are crucial to the health of patients.
The NHS Confederation has set out its own view of strategic commissioning: a cycle that sees commissioners design services based on intelligence about population need, alongside providers and local authorities, that shift resources away from hospitals and into community-based, preventative care. This includes a key opportunity for commissioners to move beyond procuring individual services to entire pathways of care. One example of this is Leeds Health and Care Partnership's HomeFirst Programme, an approach between the council, ICB, trusts, primary care and the voluntary and independent sector to develop a person-centred, home-first model that spans organisational boundaries.
While NHS England's own interpretation of strategic commissioning has yet to be revealed, we know that ‘strategy' has always been the role of commissioners, as they must attempt to build common focus in a complex landscape. Performance management can only do so much; there needs to be someone looking across systems with the best interests of patients in mind.
Change requires thinking like a system – seeing the connected big picture and building services around people - but acting like an entrepreneur – being agile and adaptive. Where commissioners have done this, they've driven innovation and experimentation in their patches, bringing the whole health sector along with them. This has meant increased resourcing for prevention and out-of-hospital care, working collaboratively with industries and universities to support broader social and economic development, or supporting the shift to integrated neighbourhood working. These are levers that can't be pulled once by the centre. Progress is driven by continued innovation, experimentation and strong relationships between providers and commissioners that allow both to get the most out of the resources they have available.
It's time to move beyond the debate about commissioners. Regardless of who might carry out these functions, or whether or not we call them ‘commissioners', the role they serve is crucial. Commissioning is here to stay.
