Following the long-term plan and the big changes it potentially signifies for CCGs, NHS Clinical Commissioners (NHSCC) chief executive Julie Wood talks to Nora Elias about closer collaboration and the future of commissioning
The NHS long-term plan, once it finally saw the light of day in January, focused heavily on integration, including the objective of seeing integrated care systems (ICSs) cover all of England by April 2021. While giving scant detail on how this is to be achieved, the plan did outline that it will ‘typically involve a single clinical commissioning group (CCG) for each ICS area’.
With this in mind, and given the fact that there are currently 195 CCGs (due to drop to 191 next month when additional CCGs merge) while there are just 44 of the sustainability and transformation plans (STPs) that are scheduled to transition into ICSs, it’s hard not to wonder what the emphasis on integration in general and ICSs in particular will mean for the future of CCGs.
Sharing her views on the topic with Healthcare Leader, NHS Clinical Commissioners’ chief executive Julie Wood says a key consideration is exactly how the move from STPs to ICSs will affect CCG quantities. ‘I think what we need to work through is what the right number is. I’m sure it’s not the current number of CCGs, but I’m equally not sure it will be 44,’ she says.
So far, however, little detail has been provided by NHS England on how the transition will work and what it will mean for CCGs, despite the fact that 14 STPs have already been through the process of becoming ICSs. As Ms Wood points out, ‘the long-term plan doesn’t say how many ICSs we will have’.
She adds that ‘if you mirror it on the current STP footprint, the smallest is around 300,000 and the biggest is 2.8 million, and I personally find it difficult to see that you would have just one CCG for a population of 2.8 million.
‘Think about what we can do differently’
With a likely drop in the number of CCGs over the next few years, it seems likely we will see more mergers in the near future. This would also be logical in light of the fact that NHS England last year asked CCGs to cut admin costs by 20% by 2021 and that CCGs ended 2017/18 with an overall deficit of £213m.
While supportive of closer integration, Ms Wood, who says CCG finances have become much more difficult since CCGs were first established in 2013, also recognises the financial impetus for CCGs to join forces. She is, however, keen to stress the importance of considering the reasons behind a merger, and ensuring it’s not simply a cost-cutting exercise.
‘In some cases they are not the right thing to do and we would be concerned about “enforced mergers” just to save the 20%,’ she says. Speaking on the day of an NHSCC roundtable on the topic, Ms Wood explains that the organisation is ‘working with our members to identify how CCGs can reduce costs’ in the interest of meeting that 20% target.
They are, she continues, looking at CCGs ‘that have reduced costs, what they have done and if there are any activities
that we can consider stopping’. Ms Wood points out that integration has not always been the strategy of choice for health and social care but that ‘as it’s become clear that we haven’t got sufficient resources, we need to think carefully
and together about what we can do differently’.
For NHSCC, this process has included working with NHS England, NHS Improvement, NICE and the Academy of
Medical Royal Colleges to identify 17 interventions that should be restricted on the NHS.
Published at the end of 2018, the findings of the Evidence-Based Interventions Programme highlighted four intervention that, according to NHS England, ‘should not be routinely offered to patients unless there are exceptional circumstances’ and 13 that ‘should only be offered to patients when certain clinical criteria are met’.
The programme is aiming to prevent more than 128,000 procedures deemed unnecessary.
‘The financial and, even more importantly, workforce resource we will free up if we stop interventions that we know to be ineffective or only effective in certain circumstances will allow hard-pressed clinicians to undertake other work that is effective,’ says Ms Wood.
‘For example, if we free up resources to get waiting lists back down again for the interventions that do improve health outcomes, that would be a good thing.’
‘We’ve got to modernise to develop’
The £20.5bn a year funding boost until 2023/24 that Prime Minister Theresa May announced for the NHS last year is, Ms Wood says, something NHSCC is ‘pleased about, but not enough to modernise’.
In fact, she says, ‘it’s not enough to maintain the status quo. We’ve got to modernise to stand still, let alone develop’. The 2019/20- 2023/24 funding allocations for CCGs do, she comments, contain ‘increased funding for the next few years’.
However, she adds that ‘even though there is additional funding, there are still considerable challenges ahead because a lot of this has been pre-committed to specific programmes of care.
So CCGs might find they still haven’t got the financial headwind they need. Over the next five years of the increased funding, clinical commissioners have to find a balance between using the additional investment for new developments and making sure the NHS remains sustainable for the future.’
Ms Wood and the NHSCC welcome the long-term plan’s focus on collaboration and partnership working, with Ms Wood commenting that ‘integration is absolutely key’ and that ‘as we move towards ICSs, we’re bringing everyone together to make collective decisions about how you spend the Barnsley pound or the Brighton pound’.
Minimising the competitive element that has at times characterised relationships between different parts of the health sector can, she says, only be a good thing.
‘In the past there’s been a bit of either the commissioner wins at the expense of the provider, or the provider wins at the expense of the commissioner and we need to move away from those scenarios.
‘We’re all in it together to do the best for the population that we collectively serve,’ Ms Wood says. She does not, however, believe this collaboration drive should take the shape of amendments to the law.
‘We need to make these changes in the existing statutory and legislative framework because major legislative change will stop everybody in their tracks, focusing them on the next reorganisation without delivering transformation in services and outcomes,’ she says.
‘Boost for community-based services’
Ms Wood was pleased to see the long-term plan place greater emphasis on primary and community care than has traditionally been the case in the NHS, alongside a shift towards prevention and keeping patients out of hospital as much as possible.
Noting the long-term plan’s ‘welcome boost for community-based services’, she adds that ‘keeping care out of hospital and in an extended primary care setting through primary care networks – so we have less demand on hospitals and patients are treated closer to home’ – is essential to the continued viability of the NHS.
‘When we set up the NHS on a hospital-based model in 1948, accidents and infectious diseases dominated. Today, as
a result of medical advances, public health interventions and lifestyle changes, long-term chronic health conditions provide the greatest burden of disease,’ Wood says.
‘So we need to design delivery of care that responds to very different needs.’ This, she argues, not only includes ‘prevention as a key priority’ but also social care.
‘We need to invest outside of the acute sector,’ she says. ‘Yes, we absolutely want a high performing acute sector but we also need highly performing and effective primary care, prevention, community and out-of-hospital services’. It comes back to that health system word of the moment – integration.
‘Join up care so it’s not fragmented, embrace prevention and social care, and ensure the right patient goes to the right place at the right time, with the right outcome. It sounds very simple but it’s awfully complex to deliver.
However, that’s the challenge if we are to have an NHS that is fit for the future and can meet the population needs as we move forward’.