Commissioning

The starting point of our inquiry has been our predecessors’ findings on the significant shortcomings of the current arrangements for commissioning in the NHS. Like the previous Committee, we are motivated by the desire to deliver high quality care to patients and good value to the taxpayer; and we see the need for an effective instrument to drive innovation and quality if these objectives are to be met. It is from this perspective that we have sought to ask “How do we make commissioning effective?” and reached our conclusions about the Government’s proposals.

We are mindful that the need to develop more effective NHS commissioning cannot be considered in isolation from the financial context in which the NHS now finds itself; the two issues are inevitably bound up inextricably with one another. The key priority facing the NHS in the immediate period ahead is the challenge first articulated by the NHS Chief Executive, Sir David Nicholson, in 2009 to achieve an efficiency gain of 4% per annum (“the Nicholson Challenge”) from 2011–12 (also expressed as the need to make £15to 20 billion in efficiency savings). The Committee accepts that it follows from the unprecedented scale of the Nicholson Challenge, and the widespread recognition of the weakness of existing commissioning structures in the NHS, that action to enhance the effectiveness of NHS commissioning is essential if the NHS is to deliver the pace of change implicit in the Nicholson Challenge – and therefore in the Comprehensive Spending Review. It is against this immediate challenge that the Committee believes the White Paper process should be judged.

There was a significant policy shift between the Coalition Programme, published on 20 May 2010, and the White Paper, published on 12 July 2010. The Coalition Programme anticipated an evolution of existing institutions; the White Paper announced significant institutional upheaval. The Committee does not believe that this change of policy has yet been sufficiently explained given the costs and uncertainties generated by the process. The Committee broadly shares the Government’s policy objectives so it therefore welcomes the fact that these are substantially unchanged. It does not believe however that the approach adopted by the Government represents the most efficient way of delivering those objectives. The failure to plan for the transition is a particular concern in the current financial context. The Nicholson Challenge was already a high-risk strategy and the White Paper increased the level of risk considerably without setting out a credible plan for mitigating that risk.

The Committee acknowledges the development of PCT clusters as a pragmatic response to the situation that developed following the publication of the White Paper We are concerned that the relatively protracted timescale is undermining the effectiveness of the NHS response to the Nicholson Challenge. The Committee believes it cannot be too often repeated that the commitment to generate 4% efficiency gains four years running is extremely challenging and it believes there must be a clear and effective management every step of the way if the NHS is to have a realistic chance of meeting the objectives it has been set.