Effective Commissioning: Lessons from purchasing in American managed care

It may seem odd that someone from the most overpriced, wasteful and inequitable health care system in the industrialised world should pen a report on how to make the UK National Health Service (NHS) more cost-effective. Yet from the very deregulated nature of US markets have emerged useful lessons, as the leading buyers (that's American for 'commissioners') face up to all the ways that they did not save money during the 1980s when they thought they had. My aim is to employ familiarity with both systems in order to extract 'adaptable policy lessons' that could be used in the UK. While based on a good deal of experience in the NHS over the past eight years, this report attempts to provide new ideas and fresh perspectives in an informal manner designed to stimulate discussion of fundamental issues. Discussing fundamentals, however, raises a problem about language. I do not mean the problem of figuring out how one can not only put a boot in a trunk but a trunk in a boot. Rather, I mean the highly politicised language of British health policy and how much control seems to be exercised over what people say, think and even perceive. For example, soon after the landslide victory of the Labour party in 1997, a prominent figure in health policy corrected my talking about fundholding by instructing me that 'Fundholding no longer exists.' For a moment I thought, 'My, things really have changed rapidly since I was last here four months ago.' Then I realised that there were just as many fundholders as before and that they covered half the nation. My colleague was coaching me in political correctness, but what degree of denial or mental muzzling was built into the coaching? Experiences like this make me wonder if there is a Minister of Acceptable Language who issues such edicts, to which everyone seems eager to conform, even if they know the edict makes no sense. Such practices are dangerous, even crippling, because one can no longer talk or think about something, at least in official circles where critical thought might make a difference. Fortunately, I found in subsequent weeks quite a number of policy experts talking and thinking about the f- word without getting arrested for Unacceptable Language. But the word 'commissioning' in our title is another matter. I had originally proposed that this report be titled Effective Purchasing. But when next I returned in October 1997, I was told that 'Purchasing is out.' Indeed, everyone had fallen into line with the mythical Minister of Acceptable Language by dropping the p- word and replacing it with 'commissioning.' This replacement may do the NHS, the Labour Party, and the nation a disservice; for commissioning is a fudge word that obscures accountability, and lack of accountability is a serious problem in the NHS. If I buy and you sell, everyone knows who is doing what and who is accountable. 'Commissioning', however, raises real worries. When it was first coined after the NHS reforms, I believe by Ian Carruthers about 1991, commissioning meant the same as 'commissioning a building.' You think through what will work best, from the ground up, and then you find the right people and 'commission' them to do it. The term captured the essence of 'needs-based purchasing,' the challenge still with us today to think through what configurations of health services will best meet the needs of the people served. But by the mid 1990s, 'commissioning' had become fuzzy, as in the term 'GP commissioning'.2 This meant advising the purchaser, certainly a potentially instructive role, but a kind of non-accountable, vicarious form of purchasing. This is a far cry from Carruthers, as the Chief Executive of the Dorset Health Authority, acting as an enlightened commissioner of new service configurations, with the authority and funds to back up his decision. The current plans to form Primary Care Groups and have them 'commission' services to one degree or another, in one relation or another to their health authority, invites problems of who will be responsible to whom and for what? The answer will vary greatly, and the fogginess of 'commissioning' will obscure what needs to be clarified. Beware. We are talking about spending more than £45 billion of the people's hard-earned money annually.