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Putting the spotlight on world class commissioning

19 June 2009

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Senior Associate
Commissioning for Health Improvement, NHS Institute for Innovation and Improvement

Gary joined the NHS in 1987, working predominantly on the provision and development of primary care services in the north west region. Gary is now leading the development of evidence-based approaches at the NHS Institute, which supports the NHS to transform healthcare for patients and improve the health and wellbeing of the population by rapidly developing and spreading new ways of working, new technology and world-class leadership

So, what is world class commissioning and why does it matter so much now?

We recognise that the health service is continually changing to meet the challenges of our modern society; a world very different to the one Nye Bevan lived in 60 years ago. People are living longer, lifestyles and aspirations are changing, and the nature of public health and disease is evolving.

In his interim review, Lord Darzi draws out four overarching themes for the NHS over the next 10 years.(1) He describes the vision of a health and care system that is fair, personalised, effective and safe.

World class commissioning will be central to achieving this vision. It takes a strategic and long-term approach to commissioning services, with a clear focus on delivering improved health outcomes and on tailoring the service to meet local needs.

By placing greater emphasis on prioritising investments to deliver long-term improvements and on assessing local needs, world class commissioning will be pivotal in reducing health inequalities. It’s also designed to support the shift from treatment and diagnosis to prevention and the promotion of wellbeing. This is crucial for delivering a fair health service, as lifestyle choices are responsible for as much as half the gap in health outcomes.(2)

Hand in hand with a more accurate assessment of local requirements comes the need for greater patient engagement and clinical involvement throughout the commissioning process. Increased clinical and patient input will ensure services are more closely designed to meet evolving patient needs.

Making world class commissioning a reality
So what skills does this emphasis on local knowledge, clinician and patient involvement and the long-term picture require?

The Department of Health has outlined 11 core competencies of world class organisations.(3) These put an emphasis on advanced knowledge management, analytical and forecasting skills, as well as an ability to listen to and communicate with the local community. To become world class, commissioners need to shape local services and drive continuous improvement in partnership with providers and partner organisations. They also need to take an evidence-based approach to commissioning.

At the NHS Institute, we have found that it helps for practices to think about their approach across three key areas of focus:

  • The first is about how, as an organisation, you gear yourself up to enable change by developing capability for change at all levels.
  • The second is about how you build technical capability and arm yourselves with the tools and methodologies for enhanced commissioning.
  • The third involves working with partners, developing the right approaches and connections to enable effective cross-sector commissioning.

Technical capability
Building technical capability is just as much about creating a culture in which innovation and improvement can flourish as it is about knowing the practical steps to follow to make commissioning a success.

There’s no question that there’s an appetite for innovation in the NHS. Recent data from the NHS Institute’s NHS Live network (a national learning network open to all NHS staff to share their ideas and best practice) show a 75% increase this year in the number of frontline staff who have had ideas and want to work together to make them happen.(4)

What’s important is that managers engender a culture in which the development of these ideas is encouraged. Staff need time, space and support to develop their thinking and should be encouraged to share learning and to take risks without fear of reprisals.

Prioritising commissioning opportunities
Alongside the necessary cultural shift, there is actually a very logical approach to pathway commissioning. Selecting a balanced portfolio of pathway redesign projects is the first step towards success. It’s imperative that the key decision-makers work together to develop an agreed list of priorities.

The foundation of the decision-making process is a review of current service provision to gather insights. This means you rely on existing evidence and intelligence to start with (eg, the Joint Strategic Needs Assessment, benchmarking data, patient views, etc) then move rapidly from a data-driven view of current opportunities to a list of preferred projects that balance quick wins with longer term, bigger gains.

Done well, a prioritisation process engages local stakeholders, ensures everyone’s views are heard and makes it explicit as to how decisions are reached.

Once you’ve identified potential pathway opportunities and prioritised and agreed the pathways to maximise health improvement, the next step is to explore and agree what needs to happen, structure a work programme, and then, finally, implement and review that work programme.

Project management is fundamental to supporting these pathway redesign projects. Organisations need to think about the whole range of activities required – from setting up the project team to stakeholder analysis, project planning and, ultimately, getting to business as usual.

Working with partners
Organisations develop a range of partnerships throughout the commissioning process. By further strengthening relationships, world class commissioning will ensure better links between different aspects of an individual and their care – ensuring patient pathways are highly personalised and effective.

By encouraging new services and providers, and promoting greater choice, world class commissioning will open up new opportunities for innovative local care solutions – again centred on the needs of the individual. In doing so, it will create an environment where innovation thrives and where high quality becomes the norm.

Moving towards world class commissioning
World class commissioning needs to take place at all levels for it to be successful. Research by the NHS Institute has found that primary care trusts that engaged practice-based commissioners in their commissioning processes improved engagement on all levels because everyone was working to the same objectives.(5)

World class commissioning promises to deliver better health and wellbeing for all, better care for all, and better value for all. It doesn’t represent a complete shift in ways of working, but rather builds on existing skills and is more than achievable.

1. Department of Health. Our NHS Our future: NHS next stage review – interim report. London: DH; 2007. Available from:…
2. Department of Health. World class commissioning and the Darzi  review. London: DH; 2007. Available from:…
3. Department of Health. World class commissioning: competencies. London: DH; 2007. Available from:…
4. NHS Institute for Innovation and Improvement. Boom in health  innovation inspires NHS Institute and NESTA to call for more. Press release. 12 November 2008.
5. NHS Institute for Innovation and Improvement. PTC Portal: a  resource for commissioners [homepage on the internet]. Available from:…