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In the spotlight

In the spotlight

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New models of care have been introduced by NHS England’s Five Year Forward View. Where do commissioners fit in?

April 2015 marked the second anniversary of clinical commissioning groups (CCGs), organisations which have spent most of their first two years under the policy-makers’ spotlight. They worked with providers in the quest to generate £20 billion of efficiency savings under the Quality, Innovation, Productivity and Prevention (QIPP) programme; they pooled £5.3 billion of health and social care budgets with local authorities as part of the drive to move care out of hospital under the Better Care Fund; and on the same day they turn two, will be given new powers to commission primary and some specialist care that previously sat with NHS England.

To name just a few major initiatives they have been involved in: CCGs have had to grow up fast and their expanding responsibilities can be seen as a sign of confidence in the new organisations.

The future for providers
In autumn the spotlight shifted and after years of tinkering with the local commissioning tier of the NHS, the publication of NHS England’s Five Year Forward View focussed attention firmly on to providers. The range of new delivery models outlined in the Forward View are quickly becoming part of the NHS lexicon. These include multispecialty community providers (MCPs) – an integrated out of hospital model based in primary care with specialists’ input – primary and acute care systems (PACs) that vertically integrate GP, community, hospital and mental health services, as well as new models of enhanced care for patients in care homes.

Unlike many policy documents to emerge from NHS headquarters, the plan has been greeted with enthusiasm across the NHS and beyond. This was demonstrated by the 269 bids submitted to the NHS England vanguard programme that will provide support to selected innovators keen to develop these new care delivery models. Twenty nine successful applicants were announced in March and further support will also be given to a number of ‘fast followers’ who didn’t make the first wave of the programme.

The future for commissioners
These are exciting developments for providers (and, most of all, for patients), but where do they leave CCGs? As new delivery models emerge, alongside developments in new integrated contracting models, increasingly we will see capitated chunks of CCG budgets delegated to a lead provider, or group of providers, who will bear the risk and responsibility for day-to-day management of their supply chain. This will mean some planning and buying decisions currently made by CCGs will be delegated to these new ‘super’ providers, and we may see CCGs taking on an even more strategic role.

Although this sounds like providers would strip out some of the CCGs’ functions, they would still have a very important role in overseeing new contracts and, during what is likely to be a long transition, will be key in encouraging new provider models to emerge. CCGs who have chosen to take on primary care co-commissioning will undoubtedly use these powers to drive changes in general practice and link them to new integrated delivery approaches. Across the country we can expect CCGs to evolve in different ways and at different speeds, depending on their local health and social care economy and the delivery models that emerge. Recent ‘Devo-Manc’ developments in Greater Manchester and variation in the extent of co-commissioning powers that CCGs across England will have from April underlines the diverse arrangements that will likely evolve.

Conflicts of interest
As new vanguard style providers start to take on larger parts of the NHS budget, the need to deal with potential conflicts of interest becomes more acute. It was interesting to see that 10 out of the 29 successful vanguard applications came from CCGs (or at least had a CCG as the lead name on their bid). The line between commissioning and provision has always been blurred for CCGs given they are membership organisations made up of GP providers. That inherent blurring is part of their unique selling point (USP) – the knowledge GPs have of patients from their daily clinical interactions is used to design services that meet local population needs.

However, the lines become even hazier with the development of delivery models that will often involve local GP practices, working together in networks or federations, with acute and community providers. One of the major potential benefits from CCGs’ new co-commissioning powers in primary care is that they can use their relationships with local clinicians to help encourage change in general practice. But where to draw the line? Can they automatically contract services from these new providers and how can they make objective decisions when they are involved in the new delivery models themselves? We know some vanguard sites have asked for reduced regulation to help them get off the ground, but how long before alternative providers start to claim their place in the market?

This issue may sound intractable, but it does not need to stall progress. CCGs and providers must strengthen efforts to manage conflicts of interest by ensuring transparent, fair and open decision-making, drawing on lay people and others to provide scrutiny over commissioning decisions where needed.

Demonstrating probity is almost as important as probity itself; to avoid becoming mired in legal challenges, CCGs must publicly demonstrate effective management of conflicts. The tricky part will be to do this while maintaining clinical involvement in their operations.

Leadership development
Successful new delivery models will also need skilled clinical leaders at their helm, meaning CCGs will have to compete for GP leaders’ time. GPs may be more attracted to roles in provider organisations closely linked to their clinical practice. However, in both commissioner and provider roles, clinicians will need to be properly supported to take on new leadership positions that are quite different from the work they trained in. In January we surveyed GPs in CCG leadership positions across six CCGs as part of an ongoing research project by The King’s Fund and Nuffield Trust. Only one third felt they had enough time to fulfil their CCG role and fewer than two-in-five said they had received the necessary training. Still, one-in-five of those not currently in CCG leadership roles stated they would be interested in getting more involved in the future. This appears to show an appetite among some GPs to play a greater part in transforming local health services and both CCGs and provider organisations need to harness that.

However, clinicians need to be involved in a way that avoids administrative burden. Our research saw GP members of CCG governing bodies wading through an average of 282 pages of papers before governing body meetings; in one CCG that figure was 560 pages. Working out ways to make best use of GPs limited non-clinical time will be critical in designing successful clinical leadership strategies on both sides of the provider/commissioner divide.

Blurred lines
The Forward View provides a huge opportunity for the NHS to integrate services and transform care. Although the spotlight is shining on providers, CCGs will play a major role in making change happen. Both must spend the next five years trying to take advantage of the blurring between commissioning and provision while mitigating against the accompanying risks.

Ruth Robertson, fellow in health policy, The King’s Fund.

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