A short informal guide to commissioning for mental health.

I find commissioning hard to understand. I put together this rough and ready guide to help me work out how it works.

I'm only talking about England, and I'm only talking about commissioning for mental health. I'll mention specialist commissioning, clinical commissioning groups, and public health. I don't talk about STP (sustainability and transformation plans), ICS (integrated care systems) or similar.

What is commissioning?

NHS England: "Commissioning is the process of assessing needs, planning and prioritising, purchasing and monitoring health services, to get the best health outcomes."

King's Fund: "Commissioning is the process by which health and care services are planned, purchased and monitored."

BMA: "Commissioning is the effective planning and delivery of healthcare to meet the needs of the population."

NHS Clinical Commissioners :"Commissioning is about getting the best possible health outcomes for the local population. This involves assessing local needs, deciding priorities and strategies, and then buying services on behalf of the population from providers such as hospitals, clinics, community health bodies, etc. It is an ongoing process. CCGs must constantly respond and adapt to changing local circumstances. They are responsible for the health of their entire population, and measured by how much they improve outcomes."

I'd say that a commissioner looks at the needs of their local population now, and tries to predict what those needs will be within the next 3 to 5 years. And then the commissioner will buy services from provider organisations to prevent those needs from happening, or to meet (treat) those needs when they have happened. This will involve working with stakeholders (people who provide services, people who use services) to design pathways and to design service specifications. (and that will also involve keeping up to date with national strategies and laws, like 5 year forward view or the Autsim Act). Commissioners will check that the services they bought are safe, effective, and value for money (remember this value for money bit later). And finally, this is an on-going process. They're always looking at local needs, they're always checking the pathways work, and they're always checking safety and value for money.

Where do commissioners sit within the system?

For mental health the commissioners sit in roughly four types of organisation. Some services are commissioned centrally by NHS England. Most are commissioned locally by Clinical Commissioning Groups. And then some are commissioned by the public health department of the Local Authority. The LA will also do the social care stuff. (So I'm counting the local authority twice, once for public health and once for social care).

What do NHS England commission?

NHS England do what is called "specialist commissioning". (This type of jargon, where we take a normal word (specialist) and give it a weird meaning (isn't all MH service a specialist service? No, not for commissioning) is the trickiest jargon for me.) It's easiest to give a list of these specialist services. Here's a source of further information: https://www.england.nhs.uk/commissioning/spec-services/npc-crg/group-c/

This list might be out of date, sorry. And I can't work out where I got it from. And it's allcaps because I cut and pasted it from a PDF. I think where it talks about adult eating disorders it's only talking about in-patient services for ED. (This split between "spec comm" and CCG commissioned service is important for later).

When we look at organisations we see a mix between NHS organisations and private organisations who are paid by the NHS to provide services to NHS patients. I guess Priory Group is an example of a private organisation that provides a lot of NHS treatment, mostly around inpatient treatment for eating disorder.

I have no idea what "other" means in that list.

There's lots of uses of the word "Tier" in there. Here's a nice description what that jargon means: CAMH Service Tiers. I think the system is trying to move away from that model, because "A system without tiers" was one of the five big themes of Future in Mind.

What do the clinical commissioning groups commission?

CCGs do the bulk of mental health commissioning - about 70% of it. Adult acute mental health hospitals, adult PICU, adult community teams, children's community teams: these are all commissioned by CCGs.

Here's what I think a CCG is.

For health services England is split into smaller areas. These are geographical. Each area has a Clinical Commissioning Group. There are about 195 CCGs at the moment. A clinical commissioning group is a reasonably large organisation with a traditional corporate structure - they have chief executives and boards of directors and employees. They hold large budgets. {todo add some information about funding}

What do these regions look like? Have a look at this page from NHS England about CCGs and Trusts in the South West.

You can see a mix of CCGs here. Some cover one city (NHS Swindon CCG). Some cover part of a county, but not the whole county (NHS Wilstshire CCG, which doesn't cover swindon). Some cover one whole county (NHS Gloucestershire CCG). Some cover multiple counties, or bits n bobs of multiple counties. So when I look at a town on a map there's no easy way to work out what their CCG will be. I just have to look it up somewhere.

There's a word that's used sometimes -- "co terminosity". This refers to the situation where you have a neat collection of single organisations all overlapping. Gloucestershire is a nice example. There is one ICS (Gloucestershire), one CCG (NHS Gloucestershire CCG), one local authority (Gloucestershire County Council), and one NHS Mental Health trust (2gether NHS Foundation Trust) so it's all neat and tidy. In other areas you don't get this neat overlap. You may have one CCG covering two different trusts, or you'll have one trust covering three different CCG regions and two different local authority regions. This means "what services are available to me here?" becomes a complicated question of "what is commissioned, and are you allowed to access it.

STP "footprints" (the area served by an STP) are larger than CCG footprints. There are fewer STPs than there are CCGs.

What do the local authority do?

The local authority have two commissioning roles. They do the public health bit, which is prevention (especially suicide prevention), and also often drug and alcohol services. And they commission social care as well. In some areas you get "joint commissioning". This means you have one person working for both the CCG and the LA trying to coordinate commissioning across both organisations. This is supposed to help with "joined up services". There's a long running problem faced by people with mental ill-health and substance misuse disorders where they shuffled between MH services and substance misuse services, not getting treatment from either. Joint commissioning is supposed to fix problems like that. I'm not sure if it's particularly effective in doing so.

I don't know much about local authority commissioning

Consequences

It's fair to say commissioning is confusing, especially because the structure of the NHS keeps changing every few years. Here's a couple of examples of the problems caused by current commissioning arrangements.

Remember earlier I mentioned the split between "spec comm" (NHS England) and CCG commissioning, and the "value for money" bit of commissioning? Here's where they affect services. I like early intervention models. Imagine I go to a hypothetical service provider and I say "There's great evidence for early intervention in eating disorder services, and we really should consider setting something up." That provider may say "we'd love to, but we're not commissioned to do it". So I go to the hypothetical commissioner in the CCG and say "This could save you money by reducing in-patient admission", well, that commissioner could say "We don't pay for in-patient admissions, that's paid for by NHS England. We'd love to provide high intensity community based early inter What you're asking us to do is spend money to set up a service, to save a different organisation some money". So, I go to NHS England, and I say "This is better for patients and their families, and it could save you money". NHS England would want to see a robust package of evidence, because they really do want to see that services are good value for money. This means that it's very difficult to get someone to actually pay for a thing that everyone agrees would be better for patients and their families, and better for staff.

Imagine a mental health trust that covers 2 CCG regions. Let's use 2gether as an example. They provide services in Gloucestershire and Herefordshire. So, if you live in Gloucestershire and want to use a recovery college you can, because Gloucestershire CCG commission that service. But if you live in Herefordshire you can't, because Herefordshire CCG don't. To me this feels like the post-code lottery has been baked into the system.

And of course sometimes this complexity is used against us. "We can't do that because commissioning" is sometimes a way to shut down conversations. I don't know what the answer is.

There are lots of things like this. Commissioning is hard to understand.