Commissioners must be at public's service

The Guardian - February 7, 2007
David Brindle

Original text from

Fifty senior managers in Birmingham city council's adults and communities department have been set some homework. Director Peter Hay has told them to team up with people who use the council's services to find out what their experiences are and what kind of outcomes are produced, with a view to feeding back the findings into how the authority goes about arranging care and support.

Rocket science it is not, but in the world of health and social care commissioning it represents a radical step. Neglect of the commissioning function has lain at the root of much of the NHS's problems for the past 16 years, since the internal market began, and while social care's record may be better in terms of value for money, there is still a lamentable lack of attention to individual needs and preferences, relative effectiveness and what works well elsewhere.

The overall picture is so bad that Bob Ricketts, the Department of Health's "head of demand-side reform" (those job titles!), could give a conference presentation the other day with slides, entitled "Failure of commissioning" - albeit with careful use of the inverted commas. And Dame Denise Platt, chair of the Commission for Social Care Inspection, was caricaturing only slightly when, at the same event, she described dealings between commissioners and service-providers as typically just "a meeting every year and a fight over fees".

Well, things can't go on like this. The drying-up of the funding flows that have so liberally irrigated the NHS and, to a much lesser extent, social care are forcing the issue. Commissioning has got to get cleverer, quickly, so that available resources deliver more outputs and better outcomes. The pending comprehensive spending review may not yet be done and dusted, but nobody in health and social care is expecting to be dancing in the streets when they hear the results.

Part of all this has to be a discernible shift in NHS spending away from acute hospitals to community services. When ministers published a year ago the community services white paper, Our Health, Our Care, Our Say, they foreshadowed diverting 5% of hospital funding in this way. Ricketts says these changes must start this year, but he is "really quite worried" about prospects because so many primary care trusts are still recovering from reorganisation and may simply default to existing hospital contracts.

Such conservatism has certainly confounded previous attempts to invigorate commissioning. But there's something else happening, quite separate from the macro spending picture, which means that the ground is shifting under the feet of commissioners and making it impossible for them to stand still. Here's how one observer sums it up: "The public become not the passive recipients of state services, but the active agents of their own life. They are trusted to make the right choices for themselves and for their families. They become doers, not the done-for."

That was Tory leader David Cameron, speaking at the recent Guardian public services summit. But it could just as easily have been Tony Blair, or Lib Dem leader Sir Menzies Campbell, because all the main political parties share a goal of empowering users of services to become their own commissioners of those services. And with the growth of direct payments and individual budgets - and, more important than the still-small numbers, the spreading of a culture of that kind of self-directed support - it's happening.

The government will shortly produce for consultation a commissioning framework for health, care and well-being. It will propose to allow GPs for the first time to use NHS money to commission some social care for their patients. Ricketts calls it "a cautious step, not carte blanche", but its implementation would mark a historic change. Slowly, perceptibly, the tectonic plates of commissioning are shifting.