Co-operative comissioning

The organisation’s Next steps towards primary care co-commissioning document published earlier this month states that co-commissioning is recognition that clinical commissioning group (CCGs) “are harnessing clinical insight and energy to drive changes in their local health systems that have not been achievable before now; but are hindered from taking a holistic and integrated approach to improving healthcare for their local populations, due to their lack of say over the commissioning of both primary care and some specialised services; and are unable to unlock the full potential of their statutory duty to help improve the quality of general practice for patients.”

NHS England is at pains to explain that co-commissioning is only an ‘offer’ to CCGs and that they are no means being mandated to take on any more primary care commissioning than they currently do or want to do – that is, at least for now.

They also stress that it is not a ‘one size fits all’ approach; CCGs can choose from a spectrum of commissioning arrangements that include fully delegated functions, joint decision making or simply increased involvement in the current decision making process.

However, Ian Dodge, the national director for commissioning strategy at NHS England, also says that he is “confident that co-commissioning-or delegation to CCGs-is in the best interests of patients”.

And according to Dr Amanda Doyle, NHS Clinical Commissioners co-chair, chief clinical officer at Blackpool CCG and co-author of the Next Steps document, co-commissioning and delegation will help to better assure that the right primary care services are being commissioned for the needs of a local population.  

“Those CCGs who don’t take this up will have to work with NHS England to develop primary care commissioning and services as best they can” she adds.

So where does all this leave the role of NHS England and its area teams?

Under the Health Act 2012 reforms, responsibility for commissioning primary care and specialised services was handed to NHS England, while CCGs were given responsibility for most acute and community services.

It came as little surprise when area teams, given their vastly inferior resource compared to their predecessor primary care trusts, struggled to cope with the demands placed on them.

While the performance of local area teams and their relationships with CCGs has varied widely across the country, when NHS England chief executive Simon Stevens announced a raft of cuts to the organisations’ operating costs in July, area teams were in the firing line.

NHS England is currently in the process of cutting hundreds of posts and carrying out a major restructure of the 27 area teams at the same time as rolling out co-commissioning.

The changes are a response to the organisation’s requirement to reduce its running costs by between 10-15% in 2015-16. All changes need to be carried out by April next year, when delegation and co-commissioning will also be officially launched.

At present the 24 area teams outside London each have six identical director posts and these are likely to be reduced and shared.

In a statement Mr Stevens said: “We have an outline plan for the field force in commissioning operations. We propose a much more integrated model across regions and areas outside of London so we avoid duplication and work more effectively across all parts of the organisation.

“This will obviously mean some change, especially to leadership arrangements, with area directors likely to oversee a larger geography, working more closely as part of the regional team, with each area director also taking on a national lead role for a specific topic.”

Mr Dodge is under no illusion that NHS England’s mandate is not set in stone and any new Government could use its powers to close the organisation down, but he is hopeful that before that happens the body will have shown its worth.

He says that commissioning of primary care is only a small part of what NHS England do and that although there is the suggestion that the next step will be the co-commissioning by CCGs of some specialist services the national body will still have a big commissioning mandate of 

its own.

“NHS England will still commission primary care services where CCGs do not want to take up the choice of co-commissioning or delegation and we will still be commissioning the bulk of specialist services as well as our unsung commissioning functions around public health,” he says. 

And not all primary care commissioning is up for grabs: community pharmacy, dental services and eye care will stay with NHS England; as will registration, revalidation and the appraisal of GPs. NHS England will also be responsible for the administration of payments and list management. NHS England has also acknowledged that the resources available for CCGs to implement co-commissioning and full delegation and those available to local area teams to continue to commission will be extremely tight. 

The Next Steps document states: “A significant challenge of primary care co-commissioning is finding a way to ensure that CCGs can access the necessary resources as they take on new responsibilities. Pragmatic and flexible local arrangements for 2015/16 will need to be agreed by CCGs and area teams.”

It continues: “Both CCGs and NHS England recognise the difficulties of managing this fairly and in a way that both supports those CCGs which want to take on co-commissioning responsibilities and allows area teams to continue to safely and effectively deliver their remaining responsibilities.

“Primary care commissioning is currently delivered by teams normally spanning several CCGs, and also covering all parts of primary care not just limited to general practice. There is no possibility of additional administrative resources being deployed on these services at this time due to running cost constraints.”

NHS England’s aim is to ensure that both CCGs and local area teams have a “fair share” of the existing administrative resources to commission effectively. 

And it has already said that given the limited size of existing area teams potentially only part-time capacity will be available for CCGs.

It has suggested that CCGs consider collaborative staffing arrangements with each other or the integration of primary care commissioning support with wider commissioning support from their commissioning support unit (CSU). 

“It will be critical that local conversations are handled with maturity and due regard for members of staff involved to ensure transparent and mutually workable solutions,” it adds.

Despite this, Dr Doyle says she is confident that most CCGs will still want to opt for co-commissioning and delegation.

“We recognise that this [having no extra funding or resources] will be a problem but local area teams are committed to looking at how this can be done with the existing capacity,” she explains.

Dr Steve Kell, co-chair of NHS Clinical Commissioners and chair of Bassetlaw CCG, says that while he agrees in principle with the idea of co-commissioning and delegation he is very concerned that CCGs will be given a poisoned chalice if they are not given any extra resource to do take on their extra commissioning role.  

“I am concerned about whether CCGs will have the resources needed to succeed,” he explains. 

Ben Gowland, chief executive of Nene CCG, agrees and warns that how CCGs operate their commissioning function and manage their new relationships will also need to stand up to public scrutiny. 

“How will CCGs be protected when they exposed to GP practices and to the general public?  Joint commissioning could work providing CCGs are given the right cover,” he says.

And Ruth Robertson, health policy fellow at the Kings Fund warns that the issue of capacity that is already a problem for local area teams will simply be transferred over to CCGs.

For now it remains to be seen how CCGs will respond to the NHS England’s new offer and take up the call to commission more widely. Those who are interested have until January to submit their applications and their new commissioning role is set to be rolled out from April.

As for NHS England’s future the picture is far from clear, much will depend on how well it succeeds in cutting back its operating costs, handling the delegation and co-commissioning agenda, and of course what flavour of Government is elected next year.