Local leadership

With co-commissioning in full swing those with delegated powers have been able to go ahead and make decisions for their populations. Birmingham CrossCity outlines what it has done so far

NHS Birmingham CrossCity CCG was in the first tranche of clinical commissioning groups (CCGs) who were approved by NHS England earlier this year to take on delegated commissioning. Delegated commissioning is when a CCG assumes full responsibility for commissioning general practice services.
We wanted to make local integrated commissioning arrangements – both in and out of hospital – a reality. Our delegated powers will enable us to provide a more joined-up and high-quality service for the people of Birmingham.
As a CCG, we feel that this can be a major step forward in improving healthcare for the people of Birmingham and will allow us to help develop and nurture general practice, which is rightly seen as one of the jewels in the crown of the NHS. One of the key benefits of having delegated authority means that we have the opportunity to implement more flexible and effective incentive schemes locally. This should encourage and enable innovation, and of course, improve patient care, which is our ultimate aim.

Changing society
With more than 90% of patient contact taking place in a GP surgery, general practice is seen as the bedrock of the NHS. It is widely accepted that small changes, for good or for ill, can make a significant difference to how the system as a whole can function. It is vital for us to further improve the already very good services that are available from practices. This has to be done sensitively and sensibly at a time of difficulty for general practitioners, whose workloads have dramatically increased over the past few years and are also experiencing a significant recruitment crisis.
In addition to this, general practice has become relatively underfunded over the past decade. Once around 10% of the budget was spent in primary care, now (depending on what statistics you choose to believe), this is less than 7%. Society has also changed, demand has increased and as well as continuity, our patients now seek improved and sometimes instant access. The complexity and acuity of the patients now dealt with in our local surgeries has dramatically increased, so against this rather difficult backdrop, we have nevertheless decided to take on this role (delegated commissioning). It is possible that Sir Humphrey from the BBC’s sitcom, Yes Minister might describe it as a ‘courageous’ decision.

It’s ace
The ACE (Aspiring to Clinical Excellence) scheme, which has been in place for two years, has already been very successful in achieving real and measureable improvements in patient care. Birmingham Cross City CCG put the ACE programme together to help improve the quality of general practice across the city and bring practices up to the same standards of primary care. We have been very mindful of the learning and particular failing of the old local enhanced scheme (LES) initiatives, where due to the very patchy uptake, it meant that a universal offer and therefore a real sustained shift in place of care and resources was almost impossible to achieve.
With 100% of our practices signed-up to ACE foundation, we have increased our disease registers and vaccination rates particularly in children. We have also improved our safeguarding processes and achieved closer working with health visitors. We have also identified many more carers and signposted them to support services, screened over 50% of patients who are over 65 for atrial fibrillation and then audited the use of stroke preventing anticoagulation in-line with The National Institute for Health and Care Excellence (NICE) guidance.
Our ACE Plus has fostered innovation, with practices developing their own proposals to test whether they can improve patient care. These cover a large range of services; from community dermatology to the avoidance of unnecessary hospital attendances, by a practice’s duty doctor providing advice to ambulance crews treating a patient in their home.
The ACE Excellence scheme (excuse the tautology, but you probably can’t have enough excellence) has acted as a major catalyst, motivating practices to work together in larger groups to deliver a universally enhanced level of patient care. For example, all of our patients now have local access to ECGs (electrocardiograms), 24-hour blood pressure monitoring and injectable treatments for diabetes.

Joining up
Following the significant success of ACE Excellence in bringing practices together, the CCG offered developmental support to all CrossCity practices to enable them to further explore several different options. We already had one large corporate practice in Midlands Medical Partnership (MMP) and now three new organisations have emerged; Our Health Partnership, Birmingham Integrated General Practice (BIG) and Eastern Birmingham Health Federation.
This has been an exciting and necessary journey to further improve and develop all of general practice for the people of Birmingham, which the CCG has importantly helped to facilitate with advice, support and appropriate resources. We will of course continue to fully support all of our practices, no matter how big or small they are.
In terms of specialised services, the CCG is part of a West Midlands regional steering group. Working with NHS England, this year we have been looking at the devolution of specialised services, for future years, as part of a national approach. We firmly believe that devolution is definitely the right thing to do and will inevitably result in improvements in quality and more efficient ways of working.
For mental health, we have a
well-established Birmingham wide joint commissioning team and we work collaboratively with Birmingham City Council and the other Birmingham CCGs. This is absolutely essential to ensure that we commission holistically and across organisational boundaries. It also ensures good, and robust working relationships with our providers. We’re confident that this approach results in us commissioning services that meet the health and social needs of our patients. This is particularly important for people with mental health needs.

The possibilities
Taking on delegated commissioning does, of course, have its complications. One that immediately springs to mind is the potential conflict of interest. How can we, as a membership organisation, commission services for our member practices; the very building blocks of our organisation? This is an area that we certainly need to be very mindful, but is one where we have been able to develop sensible and effective processes over the past two years. We have also set up what seems a very practical primary care committee and have involved the expertise of the local medical committee, so we will always be aware what is likely to be possible and what may not be!
One of the advantages of clinical commissioning is the integral involvement of clinicians and the perspective this gives us. The fact that we all spend a considerable part of our week doing the really difficult and important job of seeing our patients, should and hopefully does, give us a good understanding of the art of the possible and how we can bring our colleagues with us.
On balance, the opportunities to design and commission seamless and joined-up care, in the spirit of the Five Year Forward View, seems to substantially outweigh the complications and the difficulties. Commissioning is not just about secondary care; what happens in our surgeries and in the community is just as important, and is likely to become even more so as we seek to transform health and social care into a financially sustainable, but truly effective model. To get the best out of the system in these difficult and challenging times has required us to commission without one hand tied behind our backs; taking on this delegated responsibility has helped loosen those shackles.

Dr Gavin Ralston, Birmingham CrossCity CCG chair and local GP.