Derek Felton, MD of Tribal Health Commissioning and Ashton Leigh and Wigan PCT’s chief executive Peter Rowe explain to Health Policy Insight editor Andy Cowper in this first of four quarterly reports how they will be working together to support the development of commissioning.

Peter Rowe: Part of the story of our PCT is about our recognition that we needed dramatic improvement of our commissioning. That realisation predated the arrival of World-Class Commissioning (WCC) and the first framework for procuring external support in commissioning (FESC). It was a growing realisation from 3-4 years ago.

It was apparent then that commissioning and provision had to be two distinct functions, so we concluded three years ago that we needed to shed our provider arm and concentrate on the core business of developing GP practice-based commissioning (PBC).

When we talk about transformational change, I don't think as a PCT we were actually bad at commissioning. In fact I'd argue we were at least average, if not above-average. But we were certainly not world-class; nor did we really know what 'world-class' meant - and I'm not sure that we completely do now. Our commissioning was not changing the way local services were being delivered.

But we were thinking about what to do, and along came the FESC: we latched on via its rigorous objective to bring commissioning skills, competencies and capacity.

We liked the FESC because it was very objective, and we could see a timetable. The actual FESC process that followed was tortuous, and over-bureaucratic, but we got a great result at the end of it.

Derek Felton: The procurement process was certainly overly long, but it meant that got to know Ashton, Leigh and Wigan PCT well as we went through, which helped us develop the crucial basis of trust. Commercially, we know that the lengthy process also enabled us to put together a really innovative risk sharing agreement to lower the overall price of the contract for ALW.

The period of procurement was very professionally led by the PCT and gave us a good understanding of their personalities. It was the only procurement we saw that had active involvement of local GPs, and where there was a broad consensus across the health economy. The dialogue, questions and debates with these stakeholders during the procurement were very helpful.

FESC brought about a new relationship between the PCT and Tribal. We know that there’s no part of the programme that we can do by ourselves: we came in to this knowing the basis of our new relationship had to be a trusted partnership, which is - rightly – what was mutually expected.

One key part of partnership is the assumptions of what responsibility each partner expects from the other. You can start with a big, long list – but in the end it all comes down to one thing – to be reasonable. Now that may not sound like the basis of a good contract, but from Tribal’s point of view, we could make assumptions that the PCT would have high-quality data, endless resources, and complete availability of staff to attend training programmes, but that is just not realistic. But we expect them to be reasonable, and they expect us to be reasonable. If we both act professionally towards a common goal, we will work things out together.

The ALW contract is very different to many FESC contracts so far due to the sheer breath of services it covers – from medicines management and health equity audits assessments to invoice reconciliation and organisational development. There are obviously parts of the PCT function that we don’t touch, but what is in our contract goes to the very core of PCT commissioning responsibilities.

PR: We were clear we weren’t looking to bolt on a series of initiatives. We wanted a partner to be part of our organisation for a period of three years, to get the skills needed for world-class commissioning embedded, and to help our staff learn them.

'Too often, the NHS bolts change onto existing structures and organisations adapt to stop it working: they adapt to thwart'

Too often, the NHS bolts change onto existing structures and organisations adapt to stop it working: they adapt to thwart. We’re bringing people in with not just one discrete bit of expertise, but who can help us across the board with our commissioning.

This involves both cultures – ourselves and Tribal – in developing trust and integration, so that if you visited us in two years’ time, the joint working will be so seamless that you wouldn’t know who was a PCT person and who was a Tribal person.

HPI: What do you see as the real purpose of commissioning?

PR: The NHS has not actually done commissioning in any meaningful way ever, so this is all new terrain. So we have a blank sheet as an organisation, and can ask, “what are the health needs of the population? How, as a buyer and purchaser of services, can we use our huge financial leverage to create a system to meet those needs?”

'The NHS has not actually done commissioning in any meaningful way ever"

There are tools for commissioning: we can set out a health needs analysis; look at the evidence base; look into contracts and the market-making cycle. You see these in others systems, but I’m not sure we yet have any true definition of commissioning for the NHS.

I think we have to learn together, and apply levels of change to produce a sustainable, quality health system locally that people enjoy using and believe in. That new system will have many components, including helping people to become more responsible for their own health. This is very new territory.

Look at non-medical prescribing: there are 34,000 non-medical prescribers in UK (and about 32,000 GPs), yet only 2 % of prescriptions are written by non-medical prescribers. Then there are community matrons, health trainers … commissioning is about getting away from the ‘bolting on’ approach. There are a cohort who need healthcare services: we need to redefine the workforce to meet their needs.

'If commissioning works, it will break the old paradigm and we’ll get something that is co-produced and individually-led"

So it’s about how to incentivise people to work in different ways or new forms of work; to break down patterns of care based on professional boundaries.

If commissioning works, it will break the old paradigm and we’ll get something that is co-produced and individually-led. With our 315,000 population, this will mean that we know what each of them want from us, and that we work with them to provide what they want. It’s a total shift from where we are now, and I’m not sure I’ve seen that in the WCC competencies.

DF: I’d endorse everything Peter said. In a soundbite, commissioning means investing in the health of your population – not just financially, but saying to a subset of that population (maybe a subset of one), ‘we will work with and invest in you so you can have a healthier lifestyle, and look after you when you’re well and when you’re ill’.

Commissioning is about using public money to influence and promote behaviour change. It’s also about clinical engagement to work with people to improve their help, so the benefits of better health accrue not just to the NHS, but to the individual’s quality of life; to their employer; and to UK PLC as a whole.

HPI: What are the challenges in introducing a demand-side reform like commissioning after the provider-side reforms started far earlier, creating power asymmetries with things like FT status?

PR: It’s not just FT status for the acute sector. We’ve always run the NHS in a provider-dominated way, in all parts of the country.

I think the culture in NHS management is split into two camps – radicals like me, who are into localism; and another top-down command-and-control approach. And many people welcome the certainty that the latter school of thought (and practice) offers!

It’s a huge challenge to change NHS culture. SHAs behave in entirely different ways. NHS North West have been very keen to enable, foster amd support a more localism-style approach.

'Another big thing about provider domination is, inevitably, the politics. Providers have been so dominant that if commissioning succeeds, it will threaten that dominance and shake their powerbase"

Another big thing about provider domination is, inevitably, the politics. Providers have been so dominant that if commissioning succeeds, it will threaten that dominance and shake their powerbase. I’ve just led the children’s services review in Manchester – where it’s taken three decades to bring about change. We’ve pointed out the benefits time after time but the politics is about tribes, institutions, power, top-down vs. localism, and the culture of organisations.

It’s high-risk stuff to promote and drive change when you only have limited leverage. We don’t understand very well what motivates individuals to change; how to convince them of the need for change or how to do deals with individuals about changing behaviour. With commissioning, we could easily do a lot and still fail to stop local change-blocking behaviours, with catastrophic results.

There’s lots of inertia in the system, but by bringing Tribal in, without history or baggage, it has helped us take a different perspective on what we and our providers could change. I’ve never seen an acute trust allow teams from the PCT (and Tribal) to go in and get their hands on the shop floor: it’s been remarkable.

DF: It’s a lot is about confidence as well. Individuals who work in ALW PCT are bright, intelligent forward-thinking people who want to take risks and try new things - some work and some don’t, but we can see that there has previously been a lack of confidence in affecting change using commissioning.

With a £456 million investment a year, the PCT can lead profound change. We can give the organisation the capacity to do that. The confidence will come from a raft of strategies and improvement programmes – having support, tools, education, and a variety of different tools that drive change.

Confidence is key to commissioning – we are determined that our involvement should not reduce the confidence of PCT staff and we want to demonstrate that by working together, world-class commissioning is an attainable standard.

We seek to give the PCT reassurance that they’re actually doing fine in specific areas, and must not allow it to become overly-dependent on us, because in three years’ time, we need to leave so they can continue their journey.

HPI: What are the principal obstacles to World-Class Commissioning nationally?

PR: I’d be surprised if any PCT could actually develop the WCC competencies or would have the capacity in place within timescale required unless they’re doing something like we’ve done.

The trend to involve various overarching national agencies never quite works: the paradox is that to be world-class, commissioning must be local in its relationship with GPs, the local authorities and the population.

'I wonder if the political will to see commissioning flourish will persist as we near the general election. Transformational change causes hiatus, and controversial political barriers could arise"

It’s a nice idea that a PCT can just can buy in the back-room functions, but the complexities of setting up and running that mean you’d almost miss the point. Over the next year, I think it will become clear that PCTs will have to get a massive injection of external support to achieve WCC.

So there are major capacity issues, and I think small PCTs will really struggle in some places.

The financial situation is deteriorating fast with the recession, so the ability to take risks could be constrained. I wonder if the political will to see commissioning flourish will persist as we near the general election. Transformational change causes hiatus, and controversial political barriers could arise.

HPI: Do you think reorganisation might become the mantra?

PR: Politicians have very few levers to affect noticeable change in the NHS in an electorally-friendly timescale other than reorganisation. I suspect the scale of requirement that emerges to deliver WCC will look daunting and raise questions about the capacity to provide support. Financial constraints could drive change harder, but the sheer scale of change that WCC could effect may be politically unacceptable.

DF: The centre is expecting commissioners to balance the supply and demand side dynamics in local health systems. At the moment the supply side is much stronger and more mature. World-class commissioning can exist even if finances get constrained, in fact its even more critical.

It is vital for commissioners to make sure they understand how big a challenge it is to shift from a make-do-and–mend mindset to one of being assertive investors in health.

'Currently, there’s a disconnect: every PCT website says their mission is to improve the health of their population – but none really know how to drive sustainable health improvement and reduce the burden of ill-health"

I’d also agree with Peter: I don’t see many PCTs doing world-class commissioning without bringing in lots of extra capacity to help them think and behave differently and send different messages to the provider-side.

Currently, there’s a disconnect: every PCT website says their mission is to improve the health of their population – but none really know how to drive sustainable health improvement and reduce the burden of ill-health.

The centre say they don’t want that disconnect, so PCTs have to ‘get it’ about health and be held to account. But this is totally divorced from the NHS performance framework, which PCTs have evolved to meet.

Most PCTs have not even understood the scale of change involved in world-class commissioning, let alone started to correct their approach.

PR: We’re grappling with how to balance transformational change with statutory balance, and achieving national waiting time targets. Regulators and auditors are getting ever more particular, but they’re not moving their thinking into the area of WCC. That has to change.

'The WCC competencies don’t say what are the ingredients for long-term success"

DF: Look at the WCC competencies: if you walk in to a PCT they help you work out whether it is or is not a world-class commissioner. The WCC competencies don’t say what are the ingredients for long-term success – what you need to have in place as the foundation for going on to achieve WCC status. Like a comprehensive high quality information base about the current and predicted performance of the health system across the whole pathway, for example.

HPI: What are the principal obstacles to World-Class Commissioning locally?

PR: We struggle in engagement with local people in a way that actually makes a difference, though our social marketing work is aiming to change that. We struggle with driving change of public cultural beliefs around the NHS. People in Wigan see the NHS as the place to go when you’re sick to be fixed; there’s not a big groundswell who are terribly interested beyond that.

DF: This is a paradox. In one sense, Peter’s quite right – there is a fatalistic trend locally to see their health as inevitably poorer and life expectancy shorter, and just accept that’s their lot.

On the other hand, look at the newspapers and TV: the amount of airtime and column inches on health issues tells me people are more interested than ever in heath and healthy lifestyles.

I think Peter’s social marketing team are very imaginative, and close to the best in the NHS to convey complex health issues – making pub beermats about cancer, which, by their look, language and content, people would not directly associate as NHS material.

I think there is real public appetite for health, and the day will come when the NHS writes to an individual and discusses projected life expectancy and what could be done to improve it – to ‘add years to life and life to years’.

PR: Where we’re at now in financial terms poses real risks to our social marketing strategy. We need to achieve on waiting times, and other national demands like new services for dementia. But we must stick with social marketing.

DF: We took a team from across Wigan to Munich to look at disease management, to show them an organisation which sees behaviour change and education as core to addressing long term conditions. The trick is to embed social marketing thinking into all aspects of delivery.

'The trick is to embed social marketing thinking into all aspects of delivery'

One Tribal challenge is to integrate all the bits as one big multidisciplinary team. To get hard and lasting results on cancer involves the medical team, the public health team and the finance team. Commissioning is integrating all these people, to hit topics hard in an integrated way. That is the Holy Grail of commissioning. With finances getting restricted, it’s about being efficient as much as being effective, which means making commissioning more joined-up.

PR: We must also lever significant interaction with our workforce. Of our health visitors, who do ‘stop smoking’ work, 25% smoke (indicative of local population smoking rates). And like our local population, 50% of our workforce are overweight or obese. It’s really hard work changing the way the workforce sees themselves.

HPI: Are the IT and informatics capacity in place for you to succeed in developing WCC?

PR: We’re getting there – I recently got a senior director to focus on that exact point, I think we’re further there than we sometimes realise, and we’re also almost our own worst enemy for failing to ask for and demand it. Community and mental health services still have a way to go, but there’s a wealth of information in acute and primary care – it’s just getting and analysing it.

'there’s a wealth of information in acute and primary care – it’s just getting and analysing it'

Really making the most of this involves moving information out to the individual so it can impact their behaviour. Ultimately, they must be custodians of their own information. Healthcare professionals are very into confidentiality. Some of that is for real reasons, but some will have to change as it limits the individual’s ability to control their own health status. We have to get the balance right, but driving information down to individuals is critical.

HPI: Why did you want to work with Tribal? And you with ALW?

PR: During our evaluations we came to the conclusion that there was a cultural fit and the Tribal approach was what we wanted – and the numbers added up too! If the cultural fit and approach had not been right, the numbers would have been irrelevant.

DF: When I look back, we wrote a lot in our bids trying to convince the PCT that we technically could deliver WCC (most of which I now know was not read!). We knew cultural fit and our values were important, but not how much. We were confident about our ability to be ‘NHS-sensitive’ as we drive change, so our proposals didn’t actually talk much about this!.

We’ve invested a lot, but the process taught us a lot about who we were dealing with and what makes them tick. It’s not just about ALW selecting Tribal: Harry Potter has taught us that the wand selects wizard!

We wanted the contract really badly: it was not just about commercial gain, we believed we could do good things in ALW, and make a difference to individual people.

This commitment runs throughout our team and it stands us in great stead when we have issues and problems: this was much more than just another contract for the team. And that’s actually quite hard to convey to an NHS organisation as they’re suspicious of the private sector. I expect my team to want to make a difference to patient care every bit as much as permanently-employed NHS PCT staff would, but I know it’s not easily understood.

'we need really productive relationships with commercial partners. It’s true of the future of public services in general – but it is counter-cultural'

PR: We have learned that we need really productive relationships with commercial partners. It’s true of the future of public services in general – but it is counter-cultural.

HPI: How do recession economics affect the development of commissioning?

PR: The only answer is transformational changes. Recessions make worklessness rise, technology is increasing, the population is ageing – all of this, in with a nasty recession, could see NHS retrenchment into just basic acute.

So the NHS needs every bit of expertise to get transformation in. With the luxury of good finance, people can be less ambitious: now, there’s going to be no option to spend your way out of trouble.

I worry in the short run, when I hear people talking as if it’s all OK now. It’s not as good as it should be. Central budgets are pretty hard, and we’re always told everything is in the baseline funding. Well we have challenges here and now, and fortunately, having worked on our relationships with providers, we couldn’t be in a better place.

I would not like to have to try to get partner onside now money’s getting tight.

The great thing, which we can do a bit but where Tribal is already bringing us more ability, is to engineer ‘win-wins’. Now, conversations with acute providers are more like ‘you could be more effective and productive and shed costs’. The first time around, commissioning felt more clumsy and always taking a big stick to the acute.

DF: You have to construct ‘win-wins’ with providers or they won’t listen. The contract should be used as a last resort to effect change – other sectors such as retail and manufacturing have taught us that it is a pretty inefficient and blunt instrument.

HPI: What impact has GP practice-based commissioning had on your health economy?

PR: One reason we’re using Tribal is that our PBC programme had not made any real progress. The GP fundholding movement didn’t develop a base in Wigan – there was no cohort of GPs champing at the bit, and they had no real allegiance to working with one another.

We didn’t commit the right level of resource to support PBC, so that’s also a self-fulfilling prophecy. We needed capacity, skills and competency. One of the most successful things has been how the new team really re-engaged with GPs and now PBC is moving forward at great pace, and has caught up and overtaken structures. We saw it as our Achilles Heel

DF: PBC is a tough nut to crack, you can’t dip your toe in. It meant radically changing PCT structure to develop expert commissioners and to resource PBC properly by shifting the balance of resources. This needs bravery from the PCT, and a shift of hearts and minds to value PBC. This is the Spring 2009 agenda. We’re working with PCT Directors to drive this shift of resources or it’ll just seem like a token gesture from the PCT.

HPI: What are your metrics of success on this collaboration?

PR: There’s a set of metrics around outcomes in terms of pattern of spending and resource deployment – we need a better fit. I would expect some improvement in health outcomes and inequalities, from extant metrics.

As an organisation, it would be nice to have a high score for assurance. When Tribal exit in three years, I want to see a PCT that is fully capable; a world-class commissioner; and capable of sustaining and pushing forward.

How to metricise that? I don’t know. But it’d be a mix of competence and culture and evidence-based measures. The PCT should be assertive and respected and believed in by local people, who know what our PCT do – whatever we call ourselves, the PCT is about their health and well-being, and helping them to stay well. That would be a great success: more local belief that health could be better

DF: The contract has gots lot of clear and challenging metrics. What we’ve done in our team is look at wider benefit – the benefits realisation plan is broader than that, and it is about shared values, In three years, we want to be able to leave, proving we’ve made a difference and delivered benefits the PCT was after. Our set of metrics are much larger than what's in the contract.

HPI: What haven’t I asked you that I should have done?

DF: You haven’t asked ‘are there people at ALW who don’t like us being there?’ And the answer is yes.

We underestimated that there are those who wish we hadn’t come. That was our naivety and it is at the margins. Sometimes, we don’t know how to deal with that – the reasons are personal and complex and multi-ranging, and I think we need to deploy different hearts-and-minds strategies with the PCT for all their people.

It’s a fact of life that us arriving has been perceived by some people in the PCT as their personal failing: Tribal had to come in because they’ve not been good enough at their job. That is clearly not the case, and we try to convince them, but some people think it shouldn’t have been necessary to bring us in.

PR: It’s very difficult, where an organisation acknowledges that things which had not gone well in the past, are now going well. People are proud of what they’ve done, and I’m not sure we’ll ever overcome it, or convince those people of Tribal’s very real values. As Derek says, it’s at the margins, maybe six or seven people, which is not bad given the scale and significance of change we embarked on in September 2008.

DF: Some of it is understandable: we’ve put approximately 30 people into ALW and at least one person has described this as a jackhammer to the base of organisation.

PR: This is about a jackhammer change - a fundamental change to how the organisation works!