Clinical commissioning is in urgent need of a new sense of direction and purpose as it faces the spectre of yet another round of reorganisation after the general election.
Research by the Nuffield Trust and the King’s Fund into the workings of clinical commissioning groups (CCG) concludes that the future of the clinical role in commissioning “remains fragile”. Interest from CCG leaders is waning, and they do not have the time, money or management support to do their jobs properly.
While the media is inevitably focused on problems in hospitals, the commissioning system is also under unsustainable pressure. They have always been under-resourced, and now many of them will be “co-commissioning” primary care from April with no extra cash or staff after NHS England ruled there is “no possibility of additional administrative resources” for taking on that role. Instead CCGs have been helpfully advised to adopt “pragmatic and flexible local solutions” to running primary care commissioning, which presumably translates as overstretched staff teams taking on more work.
This is not a trivial point. The risk of conflicts of interest still looms over this whole exercise. GP leaders are now going to be overseeing contracts affecting colleagues, friends, rivals and their own surgeries without the resources to ensure watertight governance.
Who is responsible for what is becoming muddled, with a lack of clarity over the respective roles of CCGs, the area teams (also badly stretched) and NHS England? As a practice manager pointed out to the researchers, the problem is “nobody really knowing who owns primary care”. This confusion is going to impede work to improve the quality of primary care, which is supposed to be the objective of the whole co-commissioning exercise.
Clinical commissioning is being undermined from other directions. The debacle over the new tariff prices, with trust objections torpedoing Monitor’s planned pricing regime for the coming year, prevents CCGs from planning local budgets with confidence and opens up the risk of mid-year price changes triggering disputes with providers.
The failure of two commissioning support units – North West and Yorkshire and Humber – to be accredited for NHS England’s procurement framework leaves 47 CCGs facing the prospect of finding new service providers. A number of CCGs across the country have already brought support services in-house, but whether that is financially sustainable for the long term is unclear.
CCGs are working hard to collaborate more closely with neighbours in running their operations and in commissioning services, but again that takes time and resources. Inadequate resources, confused accountability and responsibilities, conflicts of interest, financial instability and unreliable support are all being piled on to organisations still finding their way less than two years after they were set up and led by people who are working part-time. No wonder other parts of the NHS complain that clinical commissioning is not making enough impact.
The future of CCGs is far from secure. They are still some distance from establishing themselves as system leaders driving clinical improvement, system efficiency and better patient experience.
But as an alternative to flying the system leader flag, CCGs are increasingly pursuing a more collaborative way of working with providers and local government. Cambridge and Peterborough CCG, for example, has set up a joint strategic planning board with the aim of moving to more integrated planning and delivery of care. With a challenged health economy, some struggling providers, significant regulator involvement and the presence of the massive Cambridge University Hospitals foundation trust on its patch, being a system integrator and change agent rather than trying to lead has to be the right approach. This is the role CCGs are increasingly fulfilling.
Clinical commissioning still has an important role to play, but it needs to be redefined for an environment of long-term financial stress and increasing collaboration between acute providers and between primary and secondary care. And, somehow, it needs to be properly resourced to drive change.
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