Clinical commissioning places general practitioners at the heart of local health planning. As clinicians, we want to ensure that we provide every service our patients want, and that every health intervention comes with the necessary aftercare and support.
There are, however, two important additional factors:
- CCGs have a set financial allocation to purchase these services
- Some interventions are ineffective for some patients
Funding for the NHS as a whole is a political decision, made nationally and determined by national economic factors. Each CCG receives an annual allocation usually based on historic levels of funding. Many areas have inherited funding deficits, unsustainable health economies and high levels of local need.
This allocation is threatened by increasing demand and patient expectation. CCGs have also been asked to contribute £1.9 billion to the Better Care Fund and to absorb the impact of retrospective Continuing Healthcare Claims, which predate CCGs.
We do not, therefore, start with a level of funding that is sufficient for the increasingly complex needs and medical technologies we see in the NHS.
Prioritising funding for procedures, sometimes referred to as rationing, is nothing new. It is certainly not a CCG phenomenon.
The NHS has had local commissioning organisations for many years, with local or regional commissioning rules usually determined with public health teams. These rules have covered cosmetic procedures as well as common surgical treatments such as cataracts, grommets and tonsillectomies.
With limited budgets and financially challenged positions some CCGs have found it difficult to remove all of these restrictions when commissioning. The need to invest in better community services, improve mental health access and address local issues mean commissioners must make difficult decisions about priorities.
This prioritisation is not just a local issue. National services also face restrictions to access based on funding rules, quality indicators or specifications that define patient characteristics. An example of the latter is bariatric surgery, where patients must pass through others ‘tiers’ of provision and have a BMI above a certain level.
GPs spend much of their time advising patients about the risks or benefits of treatments, including surgery. It is important that this personalised approach is used in our commissioning, and applied to the local population.
Commissioning has increased my own personal knowledge of pathways, quality indicators and outcomes, and has enhanced many of my clinical conversations with patients about treatment options.
Locally, we have reviewed the commissioning rules we inherited and have removed the majority of restrictions. This was done following a review of clinical evidence and discussions with local consultants who agreed ‘best practice’ guidelines to be adopted by the local hospital and in primary care.
This enabled us to remove the need for prior approval for many procedures and improved access while maintaining clinical quality. It also ensured referral quality was improved. We have now extended this to clinical areas, such as orthopaedics, where Oxford clinical scores have helped us to improve local Patient Reported Outcome Measures.
Patients often have a simple question when it comes to medical procedures: ‘Will it help me?’.
We know that there are many factors that influence this, and it is right that we balance this with individual freedoms when discussing treatment options. This is either done through commissioning or, often, by consultants before treatment.
It is cited by some as rationing, but for example, clinically advising patients to lose weight before surgery reduces risks and often improves outcomes. Many units have guidelines before joint replacement, as another example, and it is appropriate that commissioners invest in providing patients with the support needed rather than simply fund more operations in isolation.
It is important that there is a proper debate about the level of funding for the NHS and what the NHS can be expected to deliver. With important initiatives – such as seven day working, increasing regulation and a reduced social care budget – we need to be clear about the role and priorities of the NHS.
Commissioners have to achieve the best services for their populations within their local financial allocations. This includes prioritising existing services but also identifying local gaps in services and investing in these. Local needs vary, and it is essential that these decisions are made by local clinicians working with their population. Investment must follow local need, improve community services and support for the vulnerable and be focused on reducing inequality and improving outcomes.
Dr Steve Kell is co-chair of NHS Clinical Commissioners, and Chair of NHS Bassetlaw CCG. He is also a GP. Please note that the views expressed in guestblogs for the Nuffield Trust are the author's own.
Kell S (2015) ‘Rationing: An unhelpful term for the broader issue of prioritisation’. Nuffield Trust comment, 23 April 2015. https://www.nuffieldtrust.org.uk/news-item/rationing-an-unhelpful-term-for-the-broader-issue-of-prioritisation