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The future for clinical commissioning

The future for clinical commissioning
24 February 2017

Since they were set up more than three years ago, clinical commissioning groups (CCGs) have demonstrated a great ability to innovate and develop services according to a local population’s needs. They have also continually had to adapt and change the way they work. Going forward, this is something I expect to see more of, a view that is reflected in The Future Of Commissioning,1 a discussion paper recently published by NHS Clinical Commissioners (NHSCC), the membership organisation for CCGs, which I co-chair.

Since they were set up more than three years ago, clinical commissioning groups (CCGs) have demonstrated a great ability to innovate and develop services according to a local population’s needs. They have also continually had to adapt and change the way they work. Going forward, this is something I expect to see more of, a view that is reflected in The Future Of Commissioning,1 a discussion paper recently published by NHS Clinical Commissioners (NHSCC), the membership organisation for CCGs, which I co-chair.

The paper looks at the evolution of clinical commissioning and what it means for new ways of working.

Clinical leadership

As the system develops, we are unlikely to see a single model for clinical commissioning. I believe that clinical leadership embedded in the management structure of the NHS must be supported and maintained. Bringing in people like me – jobbing GPs, who aren’t enmeshed in NHS management – has been crucial to commissioning. We must preserve that local clinical voice and influence, or GPs will simply go back to the day job. The NHS – and patients – will be poorer for it.

There is already a risk of this happening. We are seeing examples of experienced commissioning leaders thinking about returning to full-time clinical practice. We need to find ways to encourage them to stay in commissioning, while nurturing new talent and supporting the leaders of tomorrow – something that NHSCC is looking to do through its leadership work. Clinical leadership is very much part of the future of commissioning and we must make sure we support it.

Focus on ‘the place’

We are already moving towards more commissioning being done across ‘a place’ with new models of care and sustainability and transformation plans (STPs). In theory, there is a fixed footprint for each CCG. In reality, since set-up we’ve been learning what geographic scale and demographic footprint works best for particular health services, and commissioning accordingly.

There is now an opportunity for CCGs to work increasingly together, creating a footprint that is more appropriate for access to health services and the quality and safety of care. This means that commissioning footprints may increase in scale in certain geographic areas, or become smaller in others. In some cases, this may result in CCGs formally merging, which is something that should be supported if it works for the local area. In other cases it will result in closer collaboration. In all cases it is critical that this is driven by what works best locally, rather than being imposed from the top or resulting in a whole-system redesign of the CCG map. In this I agree with Simon Banks, chief officer of NHS Halton CCG in Cheshire, who states in The Future Of Commissioning:‘I think the strategic direction should come from on high, but how you get there should be up to you.’

We need to get an equilibrium between the focus on the needs of the local populations, and balance that against the necessity of working at scale when doing so would be prudent and correct. There are commissioning and provision decisions that are sensible to make at scale and this is where the emerging STPs can play an important role. Our responsibility is to make sure localities are not isolated and CCGs are well placed to defend the ‘sovereignty’ and needs of the local communities they serve.

We need STPs to be successful. That is non-negotiable. It is therefore critical that we all pull in the same direction. We need a system that supports transformation and brings us all together to find solutions.

Collaborative working and increased health and social care integration

Increased collaboration, between CCGs and across the system, is certainly something we expect to see even more of through STPs and other local innovations. STPs provide potential to further break down organisational boundaries, and build on the health and care integration that is already taking place through developments such as pooled budgets and alliances. Commissioners, providers, local authorities and the voluntary sector all need to work together to look at whole-population health.

In particular, health and social care must become more integrated, given the intrinsic link between the two. In The Future Of Commissioning,1 Sarah Pickup, deputy chief executive of the Local Government Association, says: ‘I think there will be more joint working between CCGs and councils, with place-based budgets, working closely with the voluntary sector’. Closer integration is something NHSCC has called for on a number of occasions, including in Stepping up to the Place.2 This document, produced with the Local Government Association, the NHS Confederation and the Association of Directors of Adult Social Services, sets out a vision for this integration. Closer collaboration will create its own challenges and require different ways of working. There are clear benefits, ultimately for patients.

New models of care

New models of care create new opportunities. The NHS Five-Year Forward View recognises that traditional models of care need to change, which we are beginning to see with the introduction of accountable care systems, as multi-specialty community providers and primary and acute care systems start to come into effect. Commissioners are embracing these new models of care, which in some cases will lead to a change in the way we work, with some of the daily transactional elements of the job being transferred – CCGs can’t delegate their statutory functions but can contract for them to be delivered differently through these new structures. This could provide an opportunity for CCGs to focus on the strategic side of their role.

New care models need work, collaboration and to grapple with complex structural and resource issues. However, with their potential to bring about positive change, organisations may decide the benefits far outweigh the challenges.

Focus on the long term

I hope to see these developments allowing clinical commissioners to focus more on long-term strategic priorities. CCGs are already carrying out a lot of work that focuses on prevention, as demonstrated in NHSCC’s Delivering A Healthier Future.3 The shift to the two-year tariff, allocations and contracting has been a step in the right direction – even though contracting brings a challenging timescale – and a start when it comes to investing for the future. But the fact remains that often with longer-term programmes, significantly more time than one fiscal cycle is needed to reap the rewards. This is something that clinicians know, and it must be further recognised by all stakeholders in health and care – including politicians – if we are to have a long-term sustainable NHS.

Delivering within finite resources

This, of course, brings me to funding and what the NHS can and should be expected to deliver. This goes wider than the future of clinical commissioning, and to consider this, you need to consider the future of the NHS itself.

Can we stop talking about who has the deficit? Commissioner, acute trust, community provider, whoever: the money belongs to the public, and we all have a responsibility to use it wisely. I say this as we are in the middle of a two-year contracting round, in which budgets are tighter than ever. Despite this challenge, it still remains the case that the money doesn’t belong to individual organisations and we need to work together to find solutions.

Commissioners and providers alike are facing multiple challenges, including increasing demand for services and extra expectations to deliver more at pace. Cuts to social care and public health intensify these pressures.

Commissioners are having to make tough decisions about prioritisation of resources. Decisions on service changes aren’t just about finances – they are also about looking to improve patient outcomes and service delivery. It is important that we make sure our reasons for seeking changes are understood by all key stakeholders – including patients, the public, clinicians and politicians – and that we genuinely engage with them before reaching
a decision. Equally essential, however, is honest conversation with the public and politicians about expectations – and the recognition that the NHS cannot deliver everything with the funding it has. What we want to make sure of is that we have a sustainable future for the NHS that delivers high quality services for patients. Clinical commissioners will play a crucial part. It is beholden on all of us to make sure the message is clear: the NHS does have a sustainable future but only if we radically change the way we design and deliver services. We must do this based on need and strive for improved outcomes. Quality must remain central to all we do.

What is the future of clinical commissioning?

We are seeing changes in the health and care system and an evolution for CCGs. These changes are bringing challenges and opportunities for clinical commissioning and the NHS as a whole.

The future is likely to see a diverse rather than single model of clinical commissioning – but clinical commissioning is here to stay. Working with partners across the system, clinical commissioners have a crucial role in bringing about a transformed, sustainable NHS that delivers for patients.

Dr Graham Jackson is the co-chair of NHS Clinical Commissioners and clinical chair of NHS Aylesbury Vale CCG


1 The Future Of Commissioning. NHS Clinical Commissioners 2016

2 Stepping Up To The Place. NHS Confederation, NHS Clinical Commissioners, the Local Government Association and the Association of Directors of Adult Social Services, 2016

3 Delivering A Healthier Future. NHS Clinical Commissioners, 2016

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