Observations of CCG meetings, reinforced and explored through interview and documentary evidence such as CCG meeting minutes, suggested that the push for commissioners to seek information arose either because they were told to take a course of action or because they wanted to take a course of action and they needed to find out how best to proceed. In both situations, which occurred commonly across the sites, relevant information was necessary to justify the decision and to persuade others to approve and/or follow the suggested course. Decision-making was assisted through repeated cycles of finding information, persuading others, justifying proposals, finding more/different information, persuading others, etc.
The impetus when commissioners were‘told’ might be a top-down edict from the Department of Health
or Strategic Health Authority; for example, the implementation of NHS 111 and‘telehealth’ were major
national initiatives during fieldwork. One CCG found that generating their own data from the first few patients using telehealth (specifically looking at hospital utilisation) was helpful in beginning to persuade
some sceptical colleagues and to start developing an‘evidence base’ to justify the decision. Commissioners
might not have agreed with the directive or believed in its merit for their local population but, regardless,
such activities became a‘must do’ which led to the search for viable supporting information.
Alternatively, commissioners sometimes looked for information when no predetermined course existed. Sometimes, local information prompted changes. For example, in response to service user feedback one commissioning organisation needed information to develop a reablement project for those with long-term conditions. To help to decide a course of action, persuade others and justify their decisions, commissioners drew substantially on several sources including mapped patient pathways, shadowing key clinicians and meetings between service users and senior commissioners. These senior commissioners needed to be convinced of the priority of the problem and merit of the proposed solution to allocate funding and give senior-level support.
In either situation (being told to or wanting to make changes), commissioners searched for and pulled in information, when information was needed. Commissioners required information to build a cohesive, convincing case. In comparing GP decision-making with GP commissioner decision-making, one participant said that as a GP the decision was between the GP and the patient, but as a commissioner the decisions ‘have to stand up to extremely close, possibly legal scrutiny and have to be owned by the organisation’ (Angus, GP commissioner). As they came from publicly accountable organisations, commissioning decisions had to be resilient to challenges from many possible directions.
For example, challenges might come from clinicians and health-care provider organisations that needed to make changes themselves in order for the initiative to be a success. We encountered multiple examples of this, including commissioners in two case site CCGs who were rolling out risk assessment tools to general practice staff, with variable success.
Service users and the public sometimes needed to be persuaded. In one CCG, engaging the public was a way to smooth the introduction of potentially unpalatable service alterations.
You’re talking about moving one thing to another site: people see that as closure. It’s a political
football . . . This engagement of lay members is to get them to kind of carry the message and hold you
to account before– rather than at the end stage going, ‘Well we didn’t feel like we were involved in
this,’ you carry them through.
Vidur, GP commissioner
Given the political nature of the NHS, the press sometimes posed challenges. Commissioning organisations wanted to avoid negative media attention. In observations of the boards of two CCGs, managing media
coverage was an issue. In one, a GP commissioner’s remarks had been misconstrued, leading the local
newspaper to headline that the board planned to close some hospital wards. In the other, the board
discussed managing a local protest by the political group‘38 Degrees’, which objected to the opening of
the NHS to commercial companies. A GP commissioner from a third CCG predicted that some of their future decisions about using commercial providers would probably result in headlines.
You could see tabloid press headlines,‘Money from NHS spent by non-NHS manager doing
consultancy work’.
Anthony, GP commissioner
Commissioners also needed to build a persuasive case to convince those with a policy or performance management role, such as the Department of Health and Strategic Health Authorities (and now NHS England area teams). National or regional directives could take the form of goal setting such as the
NHS Outcomes Framework or specific targets such as‘95% of patients attending accident and emergency
departments should be seen within 4 hours’. In addition, there was general commissioning guidance such
as the development of commissioning strategic plans and the Everyone Counts: Planning for Patients
2013/201435from the national NHS Commissioning Board. Commissioning organisations followed national
and regional directives with varying degrees of enthusiasm and compliance. For example, one CCG went
through the process of tendering services for the‘any qualified provider’ requirements, although they were
perfectly happy with their current provider.
Again it was an example of centralisation of things coming down from above. They said that we had to put out two or three services to any qualified provider. So the cluster decided what we should do. And one of them was ultrasound, non-obstetric ultrasound, which we have an absolutely excellent service provided by the hospital, even routine ones are done within a week, brilliant service. So why do
we do it? So there’s all this process and people – they ended up with a list of seven providers. But,
you know, it was a complete waste of time and money.
David, CCG chairperson
Sometimes commissioners were keen to follow national mandates, as these aligned with local agendas. For example, one CCG capitalised on national policy leanings on commissioning lead providers to subcontract to other providers. Several board documents mentioned that local activities had had
substantial‘interest from Number 10’ (i.e. the Prime Minister’s office) (board meeting papers). Another
CCG exhibited resistance to several national directives and consequently experienced pressure to comply.
GP commissioner:I just see how the world works and the pressure that organisations are put under
if they don’t conform. You know, these words like, ‘You are at risk. Your organisation is at risk.
You are at personal risk for this.’ And that’s not a nice thing to be (sic) on your shoulders.
GP commissioner:Yeah, or because we don’t agree with national diktat. We don’t think this works and we want to do this.
Interviewer:Yeah, so you’re identified as risky?
GP commissioner:Yeah and then you get lots of phone calls, and the chief exec gets phone calls, and
he has to speak to you going,‘Oh I’m getting a lot of flak about this. Can you not just smile sweetly
and say you’ll engage?’
Vidur, GP commissioner
Although commissioners were less likely to need to justify their decisions to this audience,‘evidence
purveyors’ were another source of pressure. ‘Evidence purveyors’ were those that generated or located
data or knowledge that might inform decision-making, such as Public Health, CSUs, Strategic Clinical Networks, Academic Health Science Networks (AHSNs), Collaborations for Leadership in Applied Health Research and Care (CLAHRCs), commercial and not-for-profit providers working in collaboration with the
CCGs and academic researchers. The‘evidence’ they provided might be unsolicited or be couched in such
a way as to be experienced as a pressure, for example the championing of the recommendations from the annual Joint Strategic Needs Assessments (JSNAs) carried out by Public Health. There was considerable variability in terms of the level of impact made by these external agencies across the commissioning case sites. Although their role is discussed in-depth in a later chapter, commissioners in one CCG in particular were, apparently, highly influenced by Public Health.
I think two areas where we’ve made a big difference is around diabetes, in terms of using a
combination of the evidence from local data and from national audit, in conjunction with the evidence
of what worked, to actually persuade CCGs that– to look at the way that they are commissioning
diabetes services, and the model, and to think about that . . . and around the evidence for diabetes education. The other area would be in evidence for cardiac and pulmonary rehab and in the familial hypercholesterolemia where we did a bit of work and actually have used the evidence of effectiveness
of screening . . . to actually get all the CCGs to agree to commission a service which we didn’t
have before.
Sandra, Public Health consultant
In addition to managing these external forces, commissioners also had to convince their internal colleagues within their particular organisational culture. Sometimes, a particular ethos permeated an organisation,
which meant that certain decisions were more acceptable than others. In one CCG, the optimistic,‘can-do’
culture influenced decision-making. The term‘cynical’ emerged in several interviews as a pejorative term
applied to those who raised queries about the feasibility of certain plans.
From the provider stuff, I think I’ve got the experience to know what is possible and what probably
isn’t, and probably being a realist . . . what the cynics call realism, and it’s supposed to be cynical, I’m accused of that sometimes. I think it’s just being realistic.
David, CCG chairperson
In summary, commissioners had to influence and collaborate with many external and internal interested parties to build a cohesive case for taking a particular course of action. This included clinicians and other health-care providers, service users, the public, the press, national and regional policy and performance managers, evidence purveyors and internal colleagues (Figure 3).
Not all forces came into play in every decision-making process and there was also variability in the strength of each, as a proposal traversed through different stages. Invariably, however, in the centre of this web of these pressurising forces, the commissioners juggled competing agendas, priorities, power relationships,
demands and their own inclinations– to make the ‘best’ decision circumstances allowed. Just as there is
an‘art of medicine’, this was the ‘art of commissioning’. Thus, to a large extent, commissioning was a
matter of pulling together the appropriate knowledge and information that would satisfice (a portmanteau
word of satisfy and suffice introduced by Simon in 195636) competing agendas, and manoeuvring the
implications of that knowledge through a complex system (Figure 4). Box 3 summarises the key points of this chapter.
National and regional performance managers The press Service users Clinicians Internal colleagues Evidence purveyors Health-care providers The public
FIGURE 3 Pressures on commissioners.
1 Organisation pressures and tensions to be negotiated before X may be included in contract for Y A 2 X is included in the contract for Y A much modified X may be included in the contract for Y There is good evidence that X is best practice for Y There is good evidence that X is best practice for Y A B 1 Organisational processes B
BOX 3 Key points of Chapter 3
l Health-care commissioning is messy, fragmented and fast paced.
l Commissioning activities include needs assessment, service design, performance management, business case development, development of service specifications, service evaluation, contract management and resource allocation.
l Commissioners sought information to build a cohesive, convincing case to inform or persuade others take a course of action.
l Commissioner juggled competing agendas, priorities, power relationships, demands and their own inclinations– to make the ‘best’ decision circumstances allowed. This was the ‘art of commissioning’.
l Commissioning largely consisted of drawing together the appropriate knowledge and information that would‘satisfice’ these competing agendas and manoeuvring that knowledge through a complex system.
Chapter 4 Models of commissioning
Introduction
Having discussed the nature of commissioning in general, we now set out the specific models of
commissioning identified in this study. The term‘model’ is used in respect of broad functional types and
not, for instance, conceptual frameworks or programme theories. The three models of commissioning were clinical commissioning, integrated health and social care commissioning, and commercial provider commissioning. Although versions of the first two models have existed for the past two decades, the third model of commercial provider commissioning is new within the English NHS context.
We make no claim that these are the only three models, but they are the ones that emerged from interview and observation data, and were categories imposed by the researchers, not the participants themselves. Moreover, the models were not mutually exclusive. For example, all of the CCG sites exhibited variants of the clinical commissioning model; the integrated health and social care model was dominant in one commissioning organisation with pockets evident in two others; the commercial provider model was the rarest, as we only found one example where commercial providers had taken over commissioning activities wholesale.
A key point to make is that in drawing together the entire data set, commonalities across the CCG case sites are perhaps overplayed. In fact, the CCG case sites were highly heterogeneous in their configurations and in how they operated. Every CCG case site had its own unique blend of commissioning models to help find its way in balancing and managing competing demands. Moreover, each commissioning model emphasised a particular type of knowledge. The principal argument of this chapter is that different models of commissioning necessarily demand different types of knowledge.