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Commissioning

Why is commissioning needed? l What is commissioning?
How does commissioning work? l The role of the public l The role of Maternal Link

Why is commissioning needed?

The NHS is undergoing major changes. The role of the NHS is being redefined from a service that treats sickness to a service that promotes good health and wellbeing. This means the focus is shifting from providing expensive hospitals (acute care) and centralised care to developing better care in the community (primary care) that is responsive to the changing health needs of the population in the community. Click here for diagrammatic representations of commissioning.

“Commissioning for health and wellbeing means involving the local community to provide services that meet their needs, beyond just treating them when they are ill, but also keeping them healthy and independent.”

(Commissioning Framework for Health and Wellbeing, 2007)

To achieve this aim care, and therefore money, needs to be taken out of hospitals and put into the community.  Maternal Link exists to increase the choice of service providers available to commissioners.  Choice creates competition which ensures high quality and cost effective service provision. 

“…investing now to reduce future ill health costs.”

(Commissioning Framework for health & wellbeing, 2007)

The problem is that PCTs cannot provide community care until they have the capacity in the community, i.e. staff, buildings, funding etc. However, PCTs cannot get the capacity in the community because it is all tied up in the acute sector, i.e. hospitals.  The current situation is a catch 22.

The reason midwifery care needs to be cut free from the acute service is so that midwives have the autonomy to adapt their practice to meet the needs of their community, in particular the most vulnerable, without having to battle against major bureaucratic hurdles.  It also means that high risk women who need hospital care receive much higher quality care with resources targeted specifically at their needs because low-risk women are not also in high risk hospital units.

Maternal Link wants to develop capacity in the community in an area that is most important for women and their families and fulfils government policy.  However, since the majority of maternity care is currently provided by the acute sector there will be some difficult decisions to be taken while the transfer to community care is made. 

What is commissioning?
Commissioning is the purchasing of services by NHS fund holders, such as PCTs. They can purchase services from existing NHS providers or from the private sector. Specific frameworks and budgets are agreed which set the quantity of care that will be provided and cost of this care.  The aim is for the service to be provided to a higher standard and in a more user friendly and cost effective way than the existing service provided by the PCT. The NHS is currently a monopoly, commissioning is the first stages in opening the NHS up to a market. 

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How does commissioning work?
Commissioning is a lengthy process but there are clear guidelines about what to do and how to do it. 

There are several key aims to commissioning which can be summarised as follows:

   1. Put the needs of service users at the centre of service design
This means talking to people and finding out what they want from their local health care service, not just assuming that the providers of the service know best.  Reaching people who do not usually have a voice in how their healthcare is shaped is particularly important.

   2. Use this information effectively
This means acting on the feedback of what people want and turning it into action.  The end result should produce a high quality service that meets people’s needs and is value for money. This is likely to involve difficult re-arrangement of services and controversial re-allocation of budgets.  However, both service users and the PCT should enter the commissioning procedure in the spirit of commitment for change.

   3. Plan for the future
The result of asking people what they want and then meeting their needs should produce a health service with a clear direction of where it is going in the future, how the needs of the population will change and what the financial issues are now and in the future.  PCTs should be aiming to produce sustainable change both in the acute sector and in primary care. All new services should also link up more efficiently with cross-provider services, such as health and social care. 

Click here for a summary of the key outcomes of good commissioning.

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The role of the public in commissioning
Commissioning should encourage local NHS organisations to talk to the people they are caring for, their local population.  The aim is to understand local needs so that resources can be tailored and responsive to the specific needs of a given population. 

This is going to be a difficult procedure for many commissioners because it will involve change and very few people like change!  However, change will produce a health service better able to help local people and promote good health and wellbeing thus preventing the demands on acute care. 

Therefore, it is important that people engage with their local health bodies to ensure research takes place, plans are formulated and change implemented. There are a number of committees and groups that lay members of the public can become a part of.  There are also board meetings that are open to the public where you can make your feelings known about their commissioning agenda.

Change will always be resisted and so is a slow process. If you want to change your local health service it is important that you get involved and make your voice heard.  The quickest way to get your voice about maternity matters officially heard is to join the ‘Maternity Services Liaison Committee’, every PCT is required to have one by law. 

To find out about how to join (or establish) your local MSLC visit the NCT website or the MSLC website. 

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The role of Maternal Link in commissioning maternity services
Maternal Link’s aim is to help the formation of contracts between PCTs, who commission services, and midwives, who provide the service.  The structure of Maternal Link is shown in the following diagram which shows the role of Maternal Link, the PCT, midwives and service users.

Maternal Link offers an ‘end to end’ commissioning service.  This means Maternal Link will work with a commissioner to identify the current situation, develop a new service and ensure that all services are financially sustainable. 

The Maternal Link team has extensive knowledge in a variety of healthcare and business sectors.  The team includes midwives, NHS healthcare consultants, financial advisors and business developers. 

   1. Maternal Link will asses the current situation, in particular identify the existing budget
       and service provision

   2. Maternal Link will identify the cost of the proposed new service and service provision

   3. Maternal Link will identify the implication of commissioning the new service on the
       existing service and help the PCT / acute service ensure both the acute and
       community service are financially viable

There is a lot of work that all PCTs are undertaking to prepare for commissioning. Before Maternal Link can become involved, key issues already need to have been worked on:

   1. Assess the needs of the population
             a. What is the current service providing
             b. What are the gaps in the current service, as perceived by service users
             c. What do the service users want

   2. Develop a long term strategy to improve health for the whole PCT
             a. What are the priorities for the coming years
             b. How will these priorities be achieved
             c. How are the local population being involved

   3. Develop a strategy that meets government policy and targets
             a. How does the future strategy fit in with government policy requirements
             b. How does the future strategy fit in with future budgets

Maternal Link can show how community midwifery services, and the “normalisation” of births can contribute to improved community health and better services over the long-term. It can then assist Commissioners with some of the later parts of the commissioning process:

   4. Establish governance arrangements

   5. Co-ordinate delivery of health and social care

   6. Forecast future demand and establish management strategy

   7. Develop financial & service delivery plans in the short, medium and long term

   8. Develop primary and secondary care capacity

   9. Establish new care pathways and referral patterns

Maternal Link will help midwives organise themselves to provide a service that can be commissioned.  If premises are required, it can assist in arranging new premises through an associated company. It will help midwives:-

   1. Create a business structure and plan its management

   2. Develop budgets and business plans

   3. Develop a costing structure for the provision of services both in the short term while
       reference costs are under review and in the longer term.

   4. Conclude a contract with the PCT for the transfer of births and natal inspections from the
       acute sector to the community service.

   5. Monitor budgets and performance targets, including establishing internal management
       systems and liaising with other parts of the health service

   6. Establish employment arrangements (including safeguarding NHS pensions)

   7. Assist with creating and maintaining high standards of care and community involvement

Maternal Link exists to ensure the future of maternity services is driven by providing women with a service that meets their needs, which is safe and financially viable, and enables midwives to utilise their skills and training in making the process of having a baby a normal life experience rather than a medical illness.

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