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Co-commissioning case study in Liverpool

Co-commissioning case study in Liverpool
3 September 2014

Co-commissioning is being implemented in Liverpool allowing services to be planned with NHS England
The NHS is a system based on strong primary care, and efficiency of such systems was illustrated once again by a recent Commonwealth Fund study.1 This happened in a climate of austerity, and those who predicated the collapse of NHS were proved wrong. 

Co-commissioning is being implemented in Liverpool allowing services to be planned with NHS England
The NHS is a system based on strong primary care, and efficiency of such systems was illustrated once again by a recent Commonwealth Fund study.1 This happened in a climate of austerity, and those who predicated the collapse of NHS were proved wrong. 
Just spending more money on health does not necessarily result in better health outcomes. The USA has the most expensive healthcare system in the world but ranks last overall among 11 industrialised countries. The measures were of health system quality, efficiency, access to care, equity, and healthy lives. The other countries included in the study were Australia, Canada, France, Germany, the Netherlands, New Zealand Norway, Sweden Switzerland, and the United Kingdom. While there is room for improvement in every country, the US stands out for having the highest costs and lowest performance – the US spent $8,508 per person on healthcare in 2011, compared with $3,406 in the UK, which ranked first overall. Overall in this period of austerity the UK moved from second overall to first.
Doomsayers have also been proved wrong when they predicted that clinical commissioners would not be able to manage the complexity of NHS care. England is unique in the Western world in having two thirds of its health service funding under the control of local family doctors and clinicians. Though the challenge the NHS faces is whole system, there is far more innovation and creativity among this part of the NHS. Of course all clinical commissioning groups (CCGs) are commissioning for a defined population, and having limited ability to commission primary care was considered to be a significant barrier for CCGs. It was in this climate that Simon Stevens laid the challenge before CCGs: “CCGs that are interested in an expanded role in primary care [are encouraged] to come forward and shown how new powers would enable them to drive up the quality of care, cut health inequalities in primary care, and help put their local NHS on a sustainable path for the next five years and beyond.”
There are clearly risks to this approach, as was manifested by the motion of local medical committees (LMC) conference in York. LMCs said proposals by NHS England for CCGs to co-commission GP contracts will “fatally damage relations between CCGs and their constituents,” and reduce CCGs’ chances of effectively commissioning other areas of care. Though this is clearly an area of risk which has to be managed, I believe that it can be managed. A number of CCGs are having discussions and have, with the support of LMCs, expressed their interest in co-commissioning primary care. 
In Liverpool we believe it is the right thing to do for our population and will help the CCG to drive up the quality of care and cut health inequalities in primary care. I wrote to all the practices in Liverpool outlining the opportunity for CCGs to co-commission primary care. The letter provided information on the current arrangements and functions of NHS England and the proposed benefits and opportunities for the CCG to undertake delegated responsibility for these areas. In addition, this has been an agenda item on each locality leadership meeting and has been discussed at the governing body. To date feedback has been extremely positive and practice members support the CCG application, however there is some concern with regards to managing conflict of interest, particularly relating to the core contract and applying sanctions. As a CCG we do not wish to have responsibility for applying contractual sanctions. We will continue to work closely with members and the LMC through implementation. We are working through those issues and are confident that we can provide assurances to our members and also NHS England that conflict of interest is being managed and relationships with our members are enhanced rather than damaged. 
In Liverpool we have embarked on the Healthy Liverpool Programme (HLP) which is an ambitious programme to redesign health services in the city in order to improve health outcomes for the population and secure sustainable, high quality services for patients. The scope of the changes required run from prevention, through primary, community and social care, to hospital care, including both general and specialised services. As such, in order to commission this new model of care we needed to take greater commissioning responsibility for the population. In terms of primary care we needed to have greater involvement in influencing decisions across all aspects of commissioning general practice services, and to have delegated responsibility for commissioning some aspects including deciding strategic priorities and managing the financial resources.
In Liverpool we have a history of being innovative, and GP specification is one example and maybe the level of trust which exists here explains the support that we have for this approach. The Liverpool General Practice Specification was developed during 2010 and implemented in April 2011. Its development was led by PBC clinicians, many of whom now form the leadership of the CCG, working with the LMC and primary care trust (PCT). I was part of the core group which developed it and was chair of a group which oversaw its implementation. The principle behind the development of the specification was to improve the health of patients by ensuring that every patient had access to consistently high-quality primary care from every practice, reducing health inequalities and variation, and ensuring the most cost effective use of resources. All Liverpool practices are commissioned to deliver the standards set within the specification, whether General Medical Services (GMS), Personal Medical Services (PMS) or Alternative Provider Medical Services (APMS), and there is an element of their funding at risk if they do not demonstrate achievement of a range of key performance indicators.  
Achievements over the past three years include:
 – Increased childhood and flu vaccination rates above national trends.
 – Reduction in prescribing rates and spending.
 – 16,000 additional people identified on disease registers.
 – Reduction in A&E attendances.
 – Reduction in unplanned admissions.
With the advent of clinical commissioning, the specification has now developed into the Liverpool quality improvement scheme (LQIS). However, this is just part of the overall primary care quality framework which was introduced by the CCG in April 2013 and continues to drive improvement in the care delivered by Liverpool’s 94 GP practices.  
The framework was developed to:
 – Support practices to deliver high quality primary care services. 
 – Assure local area team that Liverpool CCG are providing high quality primary care.
 – Ensure general practice plays its part in realising CCG vision.
The framework consists of 62 evidence-based indicators (quality and outcomes framework [QOF] and local quality indicators [LQIs]) covering prevention, cancer, cardiovascular disease (CVD), long- term conditions, children’s, urgent care, planned care and patient experience. While there is no financial risk against the indicators not related to the specification, the framework is used by practices to produce practice development plans, which the CCG supports practices to deliver.
As with the GP specification, our approach is to build on nationally agreed contracts for GMS practices, and ensure that consistent, high standards are set for all Liverpool practices, regardless of their contractual status. Liverpool CCG has 94 member practices which are organised into three Localities and work in 18 neighbourhoods. To support this structure the primary care team has three locality development managers with a team of neighbourhood support managers. Their role is predominantly to support practices in the delivery of the standards set out in the primary care quality framework, and so reduce variation across general practice. In addition, there is a manager responsible for prescribing and a commissioned medicines management team to support the practices, and a management lead for enhanced services and military health. 
Since the CCG was established, careful consideration has been given to how potential conflicts of interest are managed, and this is reflected in our governance structure.
The primary care committee meets on a monthly basis chaired by the chair of the CCG. The committee is responsible for driving continuous improvement within primary care, ensuring delivery of high quality general practice through implementation of the primary care quality framework and the neighbourhood delivery model. An NHS England representative is co-opted onto the committee. The committee is presented with clinical models only for approval, not how a decision on the service is to be procured or the financial value of any service. This is for agreement at the finance, procurement and contracting committee.
If the finance, procurement and contracting committee recommend that a service is to be commissioned from general practice, then all individual investments must be reviewed and approved by the CCG approvals committee. This is made up of six governing body members, none of who work in general practice. The committee is responsible for ensuring the CCG applies conflicts of interest principles and policies rigorously and provides the CCG with independent advice and judgment where this is any doubt. The committee plays an important role in assessing and determining the new schemes in primary care that the CCG may want to invest in.
There is an element of financial risk for practices attached to achieving the key performance indicators set out in the general practice specification. Following the implementation of the GP specification it stated that in order for practices to retain their additional investment they either have to achieve Band A or demonstrate the work that they have undertaken in striving to achieve Band A against the agreed KPIs. Within the general practice specification it states that practices who fail to achieve Band A will have the opportunity to challenge this non achievement by providing appropriate evidence. 
The CCG established a validation committee to review the evidence from practices who hadn’t achieved the KPIs. The membership of this group includes general practitioners not involved in CCG commissioning, lay member stakeholder engagement, contracts manager and deputy medical director from NHS England. The validation process operates after the end of each financial year. 
This process has clear criteria for submission of evidence and a governance structure that ensures a fair and equitable assessment of performance. To date investment has been withdrawn from a number of practices.  
So through the primary care committee, the approvals panel and the validation committee we have governance structure which sets strategy and ensures clinical sense; approves investment in general practice; and applies penalties if targets are not met. 
To summarise, in Liverpool we believe that concerns expressed at the LMC conference are valid but we already have experience that these concerns can be addressed and CCGs should meet this challenge. 
1. The Commonwealth Fund. Mirror, Mirror on the Wall, 2014 Update: How the U.S. Health Care System Compares Internationally. 2014.  Available at:

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