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With great power

With great power

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Wigan Borough was awarded delegated powers under the move to co-commissioning. Here is an outline of putting its new authority to work

Commissioning health services locally can be an effective way of ensuring high-quality services that meet local needs. This is particularly true for GP services and primary care services in general that are delivered in our communities by small providers.
The conflict of interests inherent in primary care services being commissioned by local clinicians can lead to justifiable concerns and also to complicated governance systems. However, this is more than balanced by the benefits of utilising the knowledge of local commissioners and local clinicians, who are close to their patients, understand their population, its demographics and needs.
In Wigan Borough Clinical Commissioning Group (CCG), we are committed to the integration of local provision, and this inevitably means integration of commissioning too. Local GPs are frustrated at remote system leadership that cannot, by its very nature, understand and consider the nuances of local systems, local places and local populations.
This irritation is shared by our patients too, who tell us unequivocally that they want clearer local accountability of their services. Centralising control creates distance between the patients and decision-makers. Patients want to be able to challenge the people responsible for the services around issues that are pertinent to them, including quality, access and service changes. They want to have the choice to sit in a room with the decision-makers, to write to a local address, or phone a local number, and feel like their concerns are being listened to.

Confronting the issues
Their concerns are valid. Every day there are stories in the papers that portray GP services as approaching crisis point. The Department of Health and NHS England are trying to tackle some of these issues, including low national recruitment and training of GPs and practice nurses, increased workload, and the potential time bomb of an ageing workforce with high numbers due to retire. However, the national plans – welcome though they are, focus on the long-term challenge. In Wigan Borough, like many areas, we can’t afford to wait; we need to immediately confront the issues of recruitment, retention and system resilience.
To do this we must radically redefine the role and delivery of primary care. CCGs are the only place this can be done within the tight timescales we are facing. As small, responsive organisations led by the GP practice community, we are ideally placed to influence and accelerate change. Due to strong relationships with our patient community carefully built over the last two years, we can listen, learn and consult meaningfully without delays. All this can mean rapid implementation of new ways of delivering GP services.

Future vision
Local, integrated commissioning also allows CCGs to plan services holistically and manage resources effectively. If the commissioning is too fragmented, it is impossible not to deliver fragmented services because causation and consequence are very difficult to predict, manage and mitigate across organisational boundaries and competing priorities.
We want to build on the success of our integrated neighbourhood teams that help manage our highest service users and give them better quality lives. We have a vision for community-based primary care hubs that bring together GPs, dentists, pharmacists, outpatient clinics, third sector, social services and more. These hubs will help us wrap services around our patients and deliver against all of the three pillars of primary care more successfully: prevention, urgent but non-emergency care and management of chronic conditions. They will keep at the heart of them healthcare led by local family doctors, but offer flexibility of care and efficient delivery models.

Knowing your limits
It is important to remember though that ‘local’ doesn’t always equal ‘efficient’. There are areas of healthcare that are better delivered on a larger footprint than a CCG. Where a small number of people need specialist services that require highly specialised consultants and expensive, bulky machinery to diagnose or treat, there is an obvious case to be made for commissioning at a higher level, whether that be at area team level or nationally.
Specialist commissioning is one area where ‘Devo Manc’ should reap the benefits in Greater Manchester. There are other advantages including greater flexibility to tackle the broader determinants of health and focusing on local delivery and implementation, but within a framework of a wider strategic ambition across the conurbation. One of the success criteria of Devo Manc will have to be how well it engages the local clinicians and draws them into the wider vision.

Positive impact
As CCGs have proved, clinically-led commissioning can have a significant positive impact on health systems and outcomes. In the last 12 months, life expectancy across the borough has increased overall. The life expectancy gap for men has seen a significant improvement. In 2014 results showed men who live in the poorest parts of Wigan Borough are likely to die 9.4 years earlier than those in the healthiest parts of the borough (usually the wealthier areas). Whereas in 2013 this figure was higher at 11.1 years. Part of this improvement has been derived from the willingness of the clinicians and CCGs to work more closely with our partner and provider organisations than predecessors.
In Wigan, we have a very productive relationship with our local council, due to a joint governance system for a significant programme of work around integrated care that uses resources and investment from both partners. ‘Wigan leaders’, as it is dubbed, also brings together the major providers for the area and focuses on a life-cycle approach to health and social care commissioning and provision: start well, live well, age well.
Already we are seeing the benefits that closer working can bring and we have an overarching strategy, with specific programmes of work developing under it. These range from mental health, through to alcohol abuse, community hubs, schools and more and we are collectively tackling the financial challenges we face.
We already have in place integrated neighbourhood teams that have led to a new multi-disciplinary and holistic way of managing people with long-term conditions. This has led to 2,814 patients being seen, 1,825 care plans being agreed and a 42% reduction in use of A&E by those patients.
 A data sharing agreement – Share to Care – has been signed by all organisations, including all 63 of the local GP practices, which means we can roll out the sharing of information in a safe, sustainable and scalable model, using the medical interoperability gateway (MIG). This alows the integration of social services data in to our risk stratification tool so we can see the individuals who require the most assistance across all our services, rather than just hospital users.
Without clinical leadership and engagement, most of these improvements would have halted at the front door of the GP practice due to understandable distrust of distant managerial organisations.
In Wigan Borough, as clinicians and commissioners, we look forward to tackling the challenges delegated co-commissioning brings locally, and improving the health outcomes of our patients. l

Dr Tim Dalton, clinical chair of NHS Wigan Borough CCG and local GP.

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