History repeating itself?

Jon Glasby, editor of Commissioning for Health and Well-being discusses the problems with the current re-organisation of the health service:

“George Bernard Shaw is often credited with quoting Hegel to suggest that the only thing we learn from history is that no one ever learns anything from history. For two decades, both health and social care have been seeking to separate their provision from the commissioning of services, with a series of policies designed to create more commissioning-focused organisations buying care from a much more mixed economy of public, private and voluntary providers. Although the current Health and Social Care Bill has created significant furore with accusations of ‘privatisation’, the risk of this seems to have been somewhat overstated. Instead, one of the biggest dangers is that the largest large-scale reform of the commissioning function distracts attention from the financial savings we need to make – and actually strengthens providers relative to commissioners (again).

Over time, the NHS in particular has looked to repeated structural reorganisations in order to strengthen the commissioning of services – first devolving responsibility down to GP fundholders and total purchasing pilot, and then gradually scaling back up through PCGs, PCTS and later bigger, merged PCTs. The emphasis then shifted back to the local via practice-based and now clinical commissioning. As the service structures in place shift from large economies of scale to local responsiveness and back again – it becomes abundantly clear that there is no such thing as the perfect organisational structure for commissioning. In an ideal world, there are some things we would do at the level of the individual patient, some at neighbourhood level, some at Council level, some regionally and some nationally. Given there is no one size fits all model, we might be better off trying to work out what is best commissioned at which level – rather than constantly reorganising backwards and forwards.

Added to this what we know about large-scale structural change – the negative impact it can have on morale, productivity and service development – and the current re-reorganisation of the health service seems even harder to justify. Once again we seem to be talking about the need to strengthen commissioning, whilst actually weakening it (by reorganising it and by leaving provider interests relatively intact). Over time, this seems to have made it even harder for commissioners to influence service design and delivery – as they only just start to find their feet before they are reorganised yet again.

Ironically, when you talk to public service commissioners they often seem to have acquired this job title without the training and development you might expect to take on this crucial role. Against this background, our development programmes and our new book on Commissioning for Health and Well-being are an attempt to explore what commissioning is, where it has come from and where it might be taking us. They also look at different elements of the commissioning cycle (from assessing need to procurement and market management), as well as cross-cutting issues such as joint commissioning, user involvement and commissioning in an era of personalisation. However, these are only very small contributions to a big issue – and the danger is that this learning is disrupted and some of it lost amid another wholesale reorganisation.

Deep down we seem to believe that the perfect organisational structure exists somewhere – but that we just haven’t found it yet (since 1948). Rather than assuming that this perfect structure might be just one more reorganisation away, we might be better off supporting our current commissioners better to do the job we’ve entrusted them with – and this will take time, training and development and, above all, organisational stability.”

Jon Glasby is Director of the Health Services Management Centre at the University of Birmingham and editor of a new book on Commissioning for Health and Well-being.

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