As clinical commissioning groups (CCGs) prepare for 1 April, one has to wonder how ready they really are to take full responsibility for local strategic planning and purchasing of health care.
The coming year will be one of immense challenge in terms of the quality and safety of health care, particularly in light of the Francis Inquiry’s call for a fundamental change in NHS culture.
And all of this at a time when NHS funding is flat and the NHS Commissioning Board (now NHS England) aims to deliver a substantial reduction in management costs. Throw in the steady increase in demand for care, particularly in relation to long-term conditions, and the challenges get even greater.
These are not new problems. Commissioning was introduced to the NHS in 1991 and similar challenges have reared their heads across the years. Questions have however been raised repeatedly about the effectiveness of commissioning and what it can really deliver by way of real improvements to services and value for money.
These questions are heightened at a time when CCGs as new organisations are still bedding in and may lack both experience of the transactional aspects of commissioning (such as contracting or procurement), and the long-standing relationships and sustained leadership needed to bring about change.
A newly published study of commissioning care for people with long-term conditions provides important insights for CCGs. The study, funded by the National Institute for Health Research Health Services and Delivery Research (NIHR HS&DR) Programme, examined the day-to-day commissioning work of three primary care trusts in England.
It showed how commissioners spend a surprisingly large amount of their time and energy on planning and developing services, with relatively little assessment of costs and a lack of clarity as to whether their investment of time and energy is worth the impact and outcomes.
Commissioners clearly have a preference for relational rather than transactional work – enormous energy is given to consultation, planning and review meetings and far less to the ‘harder’ elements of commissioning, such as decommissioning or tendering for new service.
What emerges is a picture of NHS commissioning, at least for long-term conditions, that is far removed from the competitive and market-oriented approach outlined in the coalition Government’s current programme of NHS reforms.
Relational work is clearly important in ‘oiling the wheels’ of commissioning. However, the message for CCGs is that the effort involved in commissioning has to be worth the outcomes. CCGs will need to think hard about the time and energy they commit to service redesign, and make clear and legitimate choices about how much engagement and development work they can afford to do.
They will need to balance the relational and transactional aspects of commissioning: encouraging providers to take a lead role in service development and redesign and so help to fill the gap left by limited capacity and resources; bringing money (and value for money) more explicitly into commissioning discussions; using contracts in a more focused manner; and exploring opportunities for reviewing, discontinuing, and re-commissioning services.
CCGs will need to bring commissioning into a new phase, at least for long-term conditions services. In these times of austerity, the temptation will be to focus on finances as the ‘day-to-day business’ of commissioning, but CCGs need to make quality of care an equally important priority.
Whilst they will need to review priorities for how they spend their overall allocation of money, they will need to work with local stakeholders such as HealthWatch and Health and Wellbeing Boards to be able to agree and defend these priorities and ensure that any changes are ultimately in the interests of the local people they serve.
For the NHS Commissioning Board, which has recently taken responsibility from the Department of Health for developing the long-term conditions strategy, there are questions about how they will use their local area teams to support CCGs in meeting the specific challenges thrown up by long-term conditions, particularly in these first few years.
Commissioning is a function that is often spoken about, but rarely examined close-up. This new research into the 'nitty-gritty' of commissioning for long-term conditions reveals the preference in the NHS for relational and collaborative working. The tough question for CCGs is: how much of this work can be afforded in future, and will their 'commissioning labour' be directed to where it is most needed?
This blog is also posted on the GP online website.
Shaw S (2012) ‘Clinical commissioning groups: ready for take off?’. Nuffield Trust comment, 1 March 2013. https://www.nuffieldtrust.org.uk/news-item/clinical-commissioning-groups-ready-for-take-off