The paradox of scale and localness in commissioning

The Nuffield Trust report is timely. Nine clinical commissioning groups (CCGs) have already planned to end the financial year in deficit.

More may end up in deficit as the financial pressure on the NHS mounts and the new funding allocation formula creates winners and losers.

The report identifies the work CCGs do in relation to engaging stakeholders as being critical. Involving clinicians, patients and the public in service redesign work has become fairly routine as CCGs try to reach their targets for quality, innovation, productivity and prevention. Yet recent financial analyses of future NHS funding offer a worst case scenario of a £50 billion gap in NHS funding.

This may well mean a return to the rationing or 'priority setting' debates of the 1990s. Some primary care trust’s (PCTs) and practice based commissioning groups (such as those in Hampshire, Nottingham and Cumbria) have developed methodologies for priority setting and /or patient engagements and established regular dialogue with local residents and clinicians to involve them in such decisions.

Overall, the recommendation that CCGs should commission collaboratively makes good sense, but the danger of this approach lies in directing too much effort outside the CCG itself

Although the 'R' word is not yet back in widespread use, CCGs would be wise to prepare themselves for robust engagement processes and some heated public discussions if they are to keep the deficit wolf from the door.

More broadly the report argues that whether deficits were caused by the distorting effects of hospital finances; poor commissioning decisions; inadequate funding or failures in leadership and relationships with local stakeholders, some of the solutions lie in scaling up the work of commissioning, with CCGs being more likely to drive change in providers if they work together.

Its recommendations include CCGs working collaboratively and constructively with neighbouring commissioners and providers; boosting management capacity; developing efficient commissioning processes with thorough analysis of local data; and gaining support from stakeholders. The suggestions are consistent with findings of another recent Nuffield Trust study of commissioning for long-term conditions.

That paper illustrated how commissioners can become so bogged down in the minutiae of small scale service re-design that they fail to make any real impact on local service delivery.

The study also raised questions about whether commissioners can make more impact through 'relational' commissioning or 'transactional' commissioning. The former is more collaborative, using iterative negotiation with providers in which commissioners are fully involved in service redesign.

The latter focuses on specifying outcomes in contracts which incentivise providers to redesign services and is the more likely approach for collaborative commissioning across CCGs.

Overall, the recommendation that CCGs should commission collaboratively makes good sense, but the danger of this approach lies in directing too much effort outside the CCG itself. The bureaucracy of collaboration is considerable, and it saps energy.

Every meeting to agree shared commissioning goals and negotiate compromises that are acceptable to all participating organisations is time away from the local coal face. A core part of the raisin d'être of CCGs is to harness the potential of peer led change and improvement to manage demand and drive transformational change.

A careful balance must be struck between collaborative commissioning with other CCGs and local work with member practices and community services to develop and transform primary and community-based care. For without fundamental service transformation, stake holder engagement about rationing and priority setting will come sooner rather than later.