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Some Rules of Real Commissioning1. If you want to save money count the money and not the ‘savings’.Understand the costs: direct and indirect, fixed and variable, average and marginal. Understand what happens to real costs with changes in activity levels or in service design. Ignore the tariff. 2. If you want to offer more care for the same money concentrate on offering more care for the same money, not on offering the same care for less money. Enable people to be noble and creative instead of resentful and resistant. 3. If you want people to change their practice, their performance, their behaviour, understand why they don’t want to, why they think their way of doing things is better than yours. Together develop good new ways of working. 4. If you want people to behave as creative, collaborative, altruistic, knowledgeable, competent, caring professionals demonstrate these characteristics yourself, and treat them (and you) with the respect and affection those characteristics warrant. Notice and enjoy feeling how wonderful it is when they do, and be curious rather than punitive when they (and you) fail to live up to that. 5. If you want the NHS to survive and flourish as a national institution remember that it belongs to the nation – to all 60 million of us. Find ways of helping us all to make a contribution that is significant, contributions that enrich our lives as well as enlarging the service. This resource of time and energy and goodwill could dwarf the tax spend. 6. If you care about health focus on health and not merely on longevity. Remember the etymological roots of ‘health’ are shared with ‘hale’ and ‘whole’ and focus on helping people and populations (and care professionals and you) to flourish. 7. If you have to make decisions that are difficult and emotional expect to find them difficult and to feel emotional. Any decision that involves limiting access to care should feel like that. If it doesn’t, question whether you should be in commissioning. Don’t rely solely on logic and don’t take refuge in QALYs. 8. If you want discussions to focus on real things and be energetic and creative use real, simple English. English a 10 year old could understand. Don’t lose the energy from important issues by expressing them in current jargon and NHS–speak. 9. If you find that you are not being perceived as one of the good guys any more, remember that you still are - and also that everyone else is too. You have moved from a position in which you had the privilege of being able to be liked and respected by your patients, to a role much more like everyone else’s. Enjoy realising how lucky you are to be a doctor, and try to stop blaming all the other good guys (guys of both sexes of course). 10. If you often use phrases like ‘bringing care closer to home’ and 'expensive hospitals’ question whether you are behaving as a commissioner or as a primary care shop steward. Real commissioning is about thinking together across boundaries about ways of offering much more care with no more money. This requires genuinely open minds and no preconceived solutions. Valerie Iles May 2012 You are welcome to use this paper in whatever way you like as long as you credit its source.
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