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What is ‘commissioning’ anyway and why do PCTs do it?	Is this privatisation of the NHS?
Why do PCTs have to separate their provider services?	What does it mean for people who need to receive these services?
What does that mean for staff who are working in PCT provider services?	When will all this happen?

What is ‘commissioning’ anyway and why do PCTs do it?

PCTs are responsible for the overall health of the general public. Previously this responsibility was held by Health Authorities but the government handed this role to PCTs when they were formed. This means that PCTs who traditionally ‘provided’ health services directly to the public now ‘commission’ these services from the best people to ‘provide’ them. In other words they buy services from organisations who then provide health services to the general public on their behalf. The money comes from central government which means that everyone receives health services free.

The best example of a PCTs commissioning role is the way that they buy or ‘commission’ hospital services from hospitals. Basically PCTs give hospitals money to do what they do and the PCT has to ensure that the hospitals provide the right kind of services to the right standards. They do this by analysing the health needs of a certain community and stipulating to the hospital what is required.  Another example is the way that PCTs ‘buy’ services from GP practices who then provide general health care on their behalf to local people. These are basic explanations but describe the overall role that PCTs play in ensuring the general public are getting the health services that they need.

But PCTs have a responsibility to ensure that every aspect of the NHS is ‘provided’ by the right people in a way that ensures the best possible health of the general public. This includes all community health services, mental health services, GP practices, maternity services, dentistry and much more. So for every element of health care the PCT has to ‘buy’ services from a ‘provider’ who is the best provider to give people the health services that they need.

The process by which PCTs buy services from providers is called ‘procurement’. But the overall description for the role that they have in analysing the health needs of a population, procuring a range of providers and monitoring the quality of services provided is called commissioning.

Practice Based Commissioning is a different term that describes the opportunities that GP practices have to dictate the services that they require for the people that they serve. GP Practices can also analyse the healthcare requirements of their local populations and ‘buy’ services that will assist them to provide the right services. At the moment they do this through their PCT who ‘commission’ services on the GPs’ behalf after they have reported their analysis and proposals.

Why do PCTs have to separate their provider services?

Traditionally, left over from the days when PCTs were Community Trusts, all community health care services were ‘provided’ from one place because that is what Community Trusts were there to do. But now that the PCTs have this new responsibility to ‘commission’ services rather than ‘provide’ them they are faced with a bit of a conflict of interest.

It has become difficult for PCTs to convince the government, their Strategic Health Authorities and themselves that they are categorically the best ‘provider’ of community health care services when they have not explored the possibility that there might be a better ‘provider’. They now how to prove that buying or commissioning services from themselves is definitely the best option for the general public.

So the main reasons why PCTs are separating their commissioning function from their provider function are;

• To satisfy everyone that the best provider is providing the best services to the general public and to remove the perception that they are fostering a monopoly by buying services from themselves;
• To ensure that people can choose from a range of different options when seeking healthcare services;
• To make sure services are of a really good quality by ensuring that there is some healthy competition between providers who want to provide services. If more than one provider wants to provide health visiting services for example the PCT can choose the one that will give people the best quality of service for the money available;
• To make sure that they are spending their money in the best possible way by proving that they have looked at different options and chosen the best one.

Is this privatisation of the NHS?

This is not privatisation of the NHS because all NHS services will still be free and many ‘providers’ are likely to be NHS bodies themselves like hospitals or mental health trusts. Even if a PCT did buy/procure services from a private company they have to follow very strict rules to make sure that they can prove that the company was the best possible provider in terms of giving excellent quality services and improving people’s health.

In fact PCTs have always commissioned health services from private contractors in the form of GPs! GP practices are, to all intents and purposes, small private companies who provide health services that are paid for by PCTs.

PCTs are being encouraged to buy services from new types of organisations who are called ‘social enterprise’ organisations. These are normally not-for-profit organisations or companies who pledge to invest any profits that they make into their local community or into developing more health services for the general public. In some PCTs the staff who are employed by the PCT to ‘provide’ services are being helped to become new social enterprise organisations that can then exist in their own right.

What does that mean for staff who are working in PCT provider services?

Inevitably this big change is causing a lot of uncertainty amongst staff who are currently employed by PCTs to provide services. Many staff are working hard to help people whilst at the same time not knowing what will happen to their service or whether they will have a job in the future.

But whilst there is still much uncertainty it is highly unlikely that any staff will lose their jobs as a result of these changes. PCTs have an obligation to the general public to ensure that they receive healthcare services free of charge and cannot simply stop providing them themselves without procuring a viable (or hopefully better) alternative.

If PCTs, having undertaken their commissioning responsibility, do decide on an alternative provider of a certain service and it is broadly similar to the existing service then staff will automatically be offered the option to transfer to the new organisation with their existing terms and conditions under TUPE regulations -Transfer of Undertakings (Protection of Employment) Regulations.

Alternatively staff can approach their PCT and have an automatic ‘right to request’ that they be enabled to set themselves up as a social enterprise organisation and retain their NHS terms and conditions but namely their NHS pensions.  The PCT then have a duty to help these staff teams to create a new social enterprise organisationthat will need to have its own infrastructure like a payroll and HR functions, IT capability and general management.

Some provider arms may wish to do this and then become a Community Foundation Trust – a totally independent NHS provider organisation that would be regulated by Monitor, the same body that regulates Foundation Hospitals. However they would need to be a large organsiation with a turnover of over £30million. They would be accountable to their local communities through their governors and members and they would be able to keep surpluses to invest in improved (and new) services for patients, and could borrow money to support these investments.

All PCTs will need to review their provider services in detail in order that they can create a ‘service specification’. This is basically a description of the service in sufficient detail as to allow any provider to work out how they would go about providing the service and how much it would cost. Whilst the PCT will predefine exactly what it wants the service to achieve, existing staff can help the PCT to understand the details of the scope of the service and some of the finer details.

What does it mean for people who need to receive these services?

It is the duty of PCTs to ensure that there is no noticeable disruption to services and that throughout this process people still receive the care and support that they need.

There is a risk that if services are out-sourced to lots of different provider organisations that people will receive disjointed services that are not working together. It is the PCTs job to ensure that they commission services carefully and cleverly to ensure that this doesn’t happen. It is likely that as part of the procurement process they will expect bidding provider organisations to describe how they will work in partnership with other providers to ensure that people receive ‘seamless’ services.

PCTs should also be encouraging the general public to say what they think about how services are commissioned and provided. And they will require providers to constantly ask their customers if they are happy with the service being provided. By looking at this public feedback and other things like complaints, accidents and health outcomes PCTs should be able to monitor whether the providers are doing their jobs well.

There are also new organisations called Local Involvement Networks (LINKs) that have been set up so that everybody and anybody can have a say about how health (and social care) services are provided. If people have an opinion about how community health services are commissioned and provided they can contact their local LINk and let them know what they think. This is not replacing the complaints service which looks at individual’s specific situations - that will stay the same; it is designed to listen to lots of people views and feed these back to the PCT so that they can shape what they are doing around the views of the general public.

When will all this happen?

This will be a slow process over the next few years and involve lots of consultation particularly with staff and the general public. Some PCTs are more advanced than others with their plans.

Overall it is expected that the whole process will take a few years. This might sound vague but it rather depends on the size of the PCT, what services they provide, how progressively they are thinking, their attitude towards their commissioning role and what their ‘provider market’ is like.

Want to know more about your PCT’s plans?

Most PCTs have good websites these days which should clearly describe their intentions on this subject. If not it can be worth looking at recent board papers and agenda items (all of which should be readily available on their websites) to see whether the issue is being discussed.

If all else fails then people can ask to talk to, or write to, Directors of Commissioning who should be able to explain the PCTs intentions.

There are some policy documents that are worth a read. We suggest;

Commissioning a patient led NHS which is available on the Department of Health Website;

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4116716

High Quality Care for All - The final report of Lord Darzi's NHS Next Stage Review.  The department of health website had a great magazine version of this which is very reader friendly.

Towards Autonomy: Lessons learned for aspirant Community Foundation Trusts is an interesting read published by the NHS Confederation. You will need to register with the NHS Confederation to download a version or order a copy from their website.