NHS trusts have recently dominated the headlines for all the wrong reasons. Last week, poor nursing care, filthy wards and a high mortality rate were exposed at Basildon and Thurrock University NHS Hospitals foundation trust, and the chair of the NHS trust in Colchester was fired.
Meanwhile, research that ranks every general hospital in England against a range of safety measures named 12 NHS hospital trusts judged to be "significantly underperforming".
A worrying pattern is emerging. Earlier this year in the spring, it was revealed that between 400 and 1,200 more people died than would have been expected at Mid Staffordshire NHS foundation trust over three years, according to a damning report by the Healthcare Commission.
It all seems a world away from targets for "world class" health commissioning, to be discussed at a conference in London today (Commissioning for quality, organised by the NHS Confederation).
Two years ago, the Department of Health and the NHS announced ambitious plans to create world class commissioning for health services Better commissioning, they argued, would mean better health services and would help people live longer, healthier lives.
The programme judges primary care trusts on 11 "competencies", ranging from governance and financial control to excellence in all aspects of a trust's operations. PCTs, which spend about 85% of the NHS's total budget, are graded from one to four, with four being the highest. PCTs grade themselves and are assessed by an independent panel of experts. The idea is that peer pressure and performance league tables will encourage PCTs to improve their commissioning.
But most of England's 152 PCTs have a long way to go before they are judged world class commissioners. In February, PCTs published their first reports on progress towards new commissioning standards. No PCT achieved level four for any of the competencies, although level three was awarded 37 times.
"Commissioning has always been the weakest link of NHS reform packages," says Nick Goodwin, senior fellow at the King's Fund, the health thinktank. "It has always been quite poor in terms of its ability to really re-engineer or re-design services."
Poor quality data
Goodwin says commissioners assume that quality is built into the service they buy, rather than questioning the quality and paying the providers only for reaching a certain level of quality. He adds that other problems with health service commissioning have included poor quality data and a limited market for health care suppliers – most services are provided by hospitals and other parts of NHS Trusts.
But the picture isn't all bad. Goodwin says PCTs are making "slow improvement" in commissioning.
The commissioner's job is a demanding one. Commissioners purchase healthcare, assess healthcare needs, identify areas for improvement, and make decisions about how NHS resources should be invested at a locality, town, or county.
Commissioners need an in-depth knowledge of public health trends, finance and accounting, procurement and project management.
At today's NHS Confederation conference, the Primary Care Trust Network, which represents most PCTs, is unveiling a report outlining ways in which health service commissioning can be improved.
One recommendation is for commissioners to get away from their desk and talk to more patients, nurses and doctors, in order to get a more realistic picture of health services.
"If you are a commissioner of health services locally, maybe relating to four or five different provider organisations, and quite a lot of smaller ones, it is not sufficient to rely on the judgment of regulators," says David Stout, director of the PCT Network. "You need to be much more proactive. You should ensure that you have an effective dialogue with local people about what they think about the quality of health care services locally and listening to local frontline staff."
It is perhaps indicative of the state of commissioning that the network feels the need to remind NHS trusts to get back to basics; you might, for instance, think that such a dialogue would be automatic.
Serious failures
The network says that when serious failures are investigated, commissioners should be asked a series of questions about whether the commissioner knew about problems in the service and, if so, what action they took and whether it was sufficient.
But the really big question, of course, is whether PCTs can improve their commissioning when they have less money coming in. Health service managers are braced for substantial cuts in government spending from the year after next. Stout admits that raising standards while cutting costs is a big challenge, but says the two goals can be complementary.
He cites the potential for a hospital to cut the number of days a patient has to remain in hospital after an operation, while retaining the quality of care, and "competitive tendering" – letting a non-NHS body, such as a private company or a charity bid to run a contract.
Others urge commissioners to focus more on identifying health problems earlier – for example, putting mental health professionals in schools. "Do you have a fence at the top of the cliff rather than an ambulance at the bottom?" says Richard Selwyn, senior consultant at PIPC, a management consultancy which advises public sector organisations.
The new commissioning appraisal system has been welcomed, and people in the health service are cautiously optimistic that things can improve. But standards in commissioning remain patchy.
"We have a very long way to go before we can reach the point where we can claim that our commissioners are world class," says Goodwin.
