Clinical Commissioning Groups (CCGs) – now approaching their second birthday – are having to grow up fast. They have cut their teeth on community and acute services, and now have the option to take up further responsibilities.
Up to half of the country's CCGs have applied for full delegated responsibility for commissioning primary care (Level 3). An estimated 10 per cent are likely to opt for 'greater involvement' with NHS England's primary care commissioning work (Level 1) with the remainder going for joint decision making with NHS England (Level 2).
Choosing the right level
What might these new roles offer in terms of the ability to commission better care for local populations?
- Level 3: For some who have opted for Level 3, it's about coherence. For others, it is a defensive move. Those in the first camp are frustrated by the challenge of developing coherent care pathways and community-based services when NHS England is shaping the delivery of primary care and holds the budget for investment in premises. Those in the latter camp are fed up with the remoteness of NHS England and the slow pace at which contract queries are handled. They are worried about how future budget cuts will be applied and they just want to get NHS England out of their hair.
- Level 2: Those choosing the middle ground (Level 2) are, perhaps, up for a greater role but concerned about the risks and uncertainties involved in extending their commissioning responsibilities.
- Level 1: There are a number of reasons CCGs might be taking this option. They may, for example, be sceptical of or in disagreement with the plans. Or they may be overwhelmed or apathetic, having too much to do and not wanting the extra work of primary care commissioning with no extra money and insufficient resources. Or it could be something else entirely. It depends on how they are weighing up the opportunities and the risks.
Opportunities of devolved commissioning
Co-commissioning is likely to bring both opportunities and challenges to those that fully engage with it. In theory at least, Level 3 CCGs will be able to invest in general practice and primary care services that support their wider plans to transform hospital and community care. They will be able to make local decisions about investing in new premises – in line with strategic goals that go beyond primary care alone.
In addition, they will have freedom to create new incentive systems and a greater role in managing practice performance. They can adjust or drop the quality and outcomes framework (QOF) and introduce local incentive programmes. This will give Level 3 CCGs new levers through which to address variations in primary care quality and performance and opportunities to align primary care incentives with their wider commissioning strategy.
Risks of devolved commissioning
These sound like great opportunities, but they have inherent risks too. What happens if performance on traditional QOF falls after a local incentive framework is introduced? What if unsophisticated or aggressive performance management of GP performance alienates GPs such that they fail to engage with wider development programmes? What assurances do CCGs have that these new arrangements will remain in place?
The last point is particularly acute for those opting for Level 3. What will that option look like for 2015/16? Much of the assurance work on budgets and systems has not yet been done. A number of CCGs that are going now for Level 2 have cited their desire to move to Level 3 in 2016/17, in the hope that there may be more clarity on how it will work then.
From reading the guidance published thus far, though, it is unclear what in reality – for 2015/16 – the real difference will be between Level 3 and Level 2. Will NHS England be able to allow all these greater freedoms, particularly if their Area Teams are still continuing to perform many of the contracting/commissioning functions no matter what level CCGs are at? Can many flowers bloom, or will this prove impossible for practical reasons?
Additional question marks
Other questions remain unanswered too. What governance arrangements will ensure an appropriate balance between clinically-led commissioning decisions; managing potential conflicts of interest and achieving whole system development? How much financial, clinical and performance risk will fully delegated CCGs inherit? How will member practices engage with this new part of the commissioning agenda?
Early guidance on co-commissioning talked of harnessing the energy and enthusiasm of CCGs . Yet CCGs are taking on co-commissioning at a time when they are working under intense financial and political pressure with their operating budgets about to fall. Co-commissioning is a big ask of relatively new and still-developing organisations.
In some ways, it raises questions about the extent to which contract management is the lever of choice for sustainable improvement and transformation in general practice. Do the benefits outweigh the costs?
Within practices, a depleted and worn out workforce is finding it increasingly difficult to respond to new incentives and contract demands. What additional methods should CCGs use alongside contracting and financial micro-incentives in order to support general practice and wider primary care services to play a full role in service transformation?
A few answers
The second report of our joint research on CCGs with The Kings Fund will be published next week. It sheds light on how CCGs have managed the pressures of the last year.
It describes the approaches taken in six case study sites to primary care development, their progress with member engagement and the impact of rising clinical demands on the contribution of GPs to clinical commissioning. It concludes with specific recommendations for CCGs and NHS England as co-commissioning comes into effect.
It may not have all the answers to these big questions, but it certainly helps us to understand how a diverse set of CCGs have responded to this rapidly evolving environment.
Rebecca is a Senior Fellow in Health Policy at the Nuffield Trust and a clinical commissioner in Greenwich Clinical Commissioning Group.
Rosen R (2015) ‘Level up: new responsibilities for CCGs’. Nuffield Trust comment, 23 January 2015. https://www.nuffieldtrust.org.uk/news-item/level-up-new-responsibilities-for-ccgs