Keep the Split

The current system in the English NHS is based on providers being separate organisations with their own Boards and various degrees of autonomy from top down performance management.  Mostly NHS providers deliver specific services, acute, community, mental health – they are in no way “integrated”.

These NHS providers compete, including with non NHS providers and the competition is central to the way the organisations get their funding.  Part of the competition is rooted in patient choice. Commissioners allocate resources based on the priorities they set and use competition for the market or competition in a market.

In very general terms in Wales and Scotland the separation of commissioning from provision has been reversed, provider organisations are integrated (although not GPs) and private provision is minimal. In the Welsh and Scottish models Local Health Boards deal with both commissioning and provision through one body with one funding stream, but there is a functional split.  So far little has yet been done to “integrate” commissioning or provision across health and social care.

Interestingly the most recent comparative study shows that within the UK (The four health systems of the United Kingdom: how do they compare?  from the Nuffield Trust and Health Foundation) there is little or no evidence that the kind of system makes any difference to care outcomes or efficiency!

In some sense all systems have some functional split between commissioning or planning and provision.  At some point decisions about priorities and allocation of funding have to be made. In a planned system as opposed to a market the providers can be involved in service planning and contribute their ideas and expertise, but the decisions have to be made free from provider dominance

In the NHS the formal Commissioner Provider split goes back to 1992 and the start of the internal market. But there are deeper roots in the 80’s and worldwide shift in the way public service provision was managed and viewed (the era of New Public Management).  After several decades of “commissioning” there is no evidence that it has delivered on any of the claims made for it.  The Health & Social Care Act ignored this and went for deepening the influence of competition and markets in the NHS with the obvious longer term aim of moving to a regulated market.

The policy platform from Labour is to move to whole person care, removing the barriers which separate physical and mental health and social care. A necessary requirement is to repeal the H&SC Act and then to progressively remove the internal market; moving to a planned system where commissioning as a function is part of strategic planning for a defined population not the mechanism to support a market.  Over time the commissioning functions for healthcare and social care should be merged.

Commissioners would regularly assess the performance of established NHS providers and look at whether opportunities existed to improve or develop services.  Where a public provider was not performing well enough then the initial response would be to try for improvement not put it into a failure regime.  In a market system other NHS bodies would watch a competitor fail; in a planned system other providers would try and help. However there will be circumstances when improvement is not possible and the service(s) should be offered to other providers (within and outside the NHS).  Existing contracts with non NHS providers would have to be honoured but would be properly and vigorously managed.

There must however be a defined procurement regime for health services to prevent commissioners from going straight to outsourcing or to a competitive tender until they have properly evaluated the current NHS provision.  Arrangements between commissioners and providers, both of which are within the NHS, would NOT be the subject of legally binding contracts but rather NHS Contracts. As no legal contract exists there is no opening for contract or competition law.

Making that change would be possible without a major top down reorganisation.

To move further towards the model adopted in Wales and Scotland requires far more.  Moving to having Care Boards which both commission and provide the full range of services would be a reorganisation on a grand scale – far bigger than that caused by the  Health & Social Care Act.  An incremental approach would have to be adopted.

A valuable step would be to remove all the barriers to integration, not just the barriers caused by “competition”.  There could be integrated providers which deliver all the services for a defined population, or this could be achieved through some lead provider model.  It should also be possible to merge commissioning and provision into a single organisation (as in Wales and Scotland).  But rather than achieving this through a big bang rigidly proscribed reorganisation each locality would make its own way at whatever pace suited it best.  This would challenge the N in NHS and require fundamental changes to the relationships which have held the NHS together since 1947 – but maybe it is time for that shift.

Conceptually at least that might work but far more detailed work is necessary.

It is possible that those who argue passionately for an end to the Commissioner Provider split may have worked out how to do it, but not published.  It has also been argued that only a full split and the complete elimination of all non NHS providers is essential to avoid EU procurement rules and the potential impact of the Trans Atlantic Trade and Investment Partnership. This is not generally agreed but either way there has been no explanation of how this change might be achieved.