clinical commissioning

Clinical commissioning groups: how to ensure their first birthday isn’t their last

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It is more than a year since clinical commissioning groups (CCGs) formally came into existence in England, and although strategic plans are slowly beginning to emerge, CCGs continue to struggle with an infrastructure originally designed to control a national system.

The 2012 Health and Social Care Act saw CCGs as the mainspring of commissioning, capitalising on general practitioners’ twin roles: dealing with patients at the ‘front door’ of the NHS and referring and coordinating their journeys through its complex institutional pathways when necessary. The notion was that general practitioners’ (albeit anecdotal) knowledge of local services could be synthesised to inform operational and strategic commissioning throughout the NHS. Giving CCGs the freedom to change services in their local health economies was intended to encourage innovative models of care that were more user friendly and (hopefully) better value for money.

However, CCG leaders found themselves the late arrivals at a party already in full swing. NHS England had established the ground rules, subsumed specialist commissioning and primary care, and determined how CCGs should work and be managed. And adding to the harsh financial pressures, CCGs found their budgets being raided for contingency and efficiency funding as well as for augmenting specialist commissioning, maintaining pre-existing private finance projects, and supporting social care initiatives.

In terms of how to engage and enthuse newcomers, this is not what textbooks recommend, but for the current policy to work CCGs must pull their weight. How can this be achieved? CCG development seems to parallel adolescence. By the time children leave home to live independently, they need to be able to deal with the physical, financial, and emotional hurdles that they will inevitably face: they must shoulder responsibility and risk.

Similarly, CCGs were intended to assume increasing responsibility for services and develop a mature relationship with NHS England through the area teams and commissioning support units. Many have commented that this is not happening and that a form of indirect cajoling has developed instead. Despite a few signs of change (such as NHS England accepting an annual survey of its performance by NHS Clinical Commissioners), the general sense is that CCGs are under-resourced in human and financial terms and that the need to cope with what is operationally urgent is preventing them from dealing with what is strategically important. If CCGs are not allowed to develop sufficient self determination, their growing frustration and enduring dependency will drive their participant general practitioners to lose interest at best and throw adolescent tantrums at worst.

CCGs were intended to be clinically driven by autonomous professionals who function better as volunteers than as conscripts. However, such professionals (especially independent general practitioners) traditionally lack experience of corporate working, and so encouraging them to consider collective needs as well as those of their individual patients and practices is key to the success of their CCG.

This is a complex challenge that needs tackling at various levels. Overt CCG leadership requires organisational expertise as well as a thorough knowledge of local context. Many of the clinical chairpeople and accountable officers still need to learn more about strategic thinking, which takes commitment as well as protected time and funding. Whether it is even possible remains to be seen; CCGs vary greatly in their arrangements and ambitions and even the roles of clinicians and managers differ considerably.

Leadership needs to be mirrored by support among members; clinical commissioning cannot succeed without ‘grass roots’ input informing strategic thinking. Support will vary, and senior (strategic) CCG staff will have different perspectives from frontline (operational) clinicians. Such differences have never previously been bridged, and consequently individual clinical decisions have rarely influenced high level strategy. If CCGs are to exploit their potential fully, this aspect of their functioning needs a lot more development, which also takes time and money. So far, neither has been prominent, with most attention being paid to traditional senior NHS leadership, and almost none apparent to its corollary, what we might call ‘followership.’

Another obstacle to the successful development of CCGs is that the commissioning of primary care is separate to that of secondary and community services. CCGs control most of the latter two but none of the former. If a CCG decides to replace a traditional hospital service with a primary care alternative, it can decommission the first but cannot directly commission the second.

If CCGs are to hold responsibility for providing healthcare for their populations (the idea implicitly underpinning their creation), then this mismatch must be removed to give them the tools and accountability needed to provide services. If we believe in localism at all, then how they use these tools should be their decision; if they choose to provide services within their own organisation rather than subcontracting with local NHS Trusts, then that needn’t constitute a conflict of interests as long as the accountability is in place.

Outcomes such as agreed levels of morbidity, patient satisfaction, timeliness, and financial probity all offer measures of accountability irrespective of the agency involved. As it stands, CCGs are unlikely to change their paradigms of care because current mechanisms discourage change rather than rewarding it. Moreover, any existing momentum is likely to dissipate as those involved become increasingly disillusioned.

With the NHS caught between rising demand and lessening funding, the system will increasingly have to do more for less. Giving working clinicians some responsibility for achieving this, by connecting their daily activity to strategic leadership, seems logical. But CCGs will have to be supported much more emphatically, politically and operationally, if we want health service policy, local services, and the needs of the whole local population to be brought together coherently.

This is a slightly revised version of a paper prepared in collaboration with Michael Dixon, and first published in the BMJ (online 2 April 2014 as BMJ 2014;348:g2306).

Open letter to Simon Stevens

writing-query-letterDear Simon

 

Despite the fact that most open letters probably never get read by their addressees, I thought that I would join the throng of correspondents writing to you: after all, if ‘crowd-sourcing’ can raise funds and drive international campaigns, maybe it can influence policies too…

As I’m sure you’ve recognized, the NHS is in a weird place at the moment. The cognitive dissonance we all accept as part of running a state controlled (i.e. politically sensitive) system in the 21st century has reached new extremes, with the rhetoric of localism (Clinical Commissioning Groups, local choices, patient involvement) being totally at odds with the reality of national inspection regimes, the imposition of ‘Clause 119’ and the central pressure to save costs that is currently exercising us all.

The short term ‘patch it and move on’ measures of the past few years have led to so many unintended consequences that we seem to be tying ourselves into ever tighter knots physically as well as politically. Here are just three examples, but there are many more:

Emergency departments are very busy because they’re available and GPs aren’t, so we try to discourage people from attending by….extending the range of services provided at A&E.

Lewisham Hospital is really successful, so its staff are rewarded by… their assets being threatened in order to prop up the failing South London Healthcare Trust.

CCGs are tasked with responsibility for the health of their populations, and encouraged by… having their resources cut and their nascent power diminished.

And so on and so on….

If we are ever to cut through this Gordian knot, here are just a few simple principles that might help:

  1. There should be clarity about the separation between procurement and provision of services: the Government is the commissioner, and the NHS is the provider. That boundary is where the strategic overview needs to be implemented, and where the money is exchanged. The NHS is then supposed to consider how services might best be delivered, with the CCGs intended to be pre-eminent in this process, providing what services they can through their GP networks, and subcontracting the rest to agencies such as hospitals and other specialized providers.
  1. Work with human nature rather than against it: people work best when they agree with their organisation’s overall purpose and when they can see some benefit from what they are doing. Thus, a consistent approach with obvious logic works better than a series of mixed and contradictory messages, especially when those messages are clearly disingenuous and even dishonest. NHS staff don’t have to agree with everything, as long as it is clear how decisions were made, and they can rest assured that there will be consistency and stability in their working lives.

Moreover, those benefits don’t have to be financial; people join the NHS because they want to make a positive difference to the lives of ill people, and want to be proud of what they do. Approval, appreciation, peer recognition, these are all useful and not nearly as inflationary as monetary markers, whose price has to constantly increase to retain their value.

  1. Make policy and stick to it, even if the Media pundits don’t like it: democracy is great, but where long term policies are concerned, the ballot box is a better place make judgments than the daily press. Populist government leads to uncertainty and instability, and in the end, loses the respect of the populace anyway, so the system should think in years, not weeks, when it makes policy.
  1. Society needs to acknowledge the clash between rising expectations and finite resources; efficiency is clearly a good thing, but no amount of cost improvement is going to keep pace with a population that expects everything, constantly, and for free. At some stage soon, we are going to have to grasp the nettle of putting the brakes on demand, whether by formally introducing the notion of rationing, charging, or excluding.

With these suggestions in mind, Simon, perhaps you should empower the CCGs to do what they are being asked to do? That’ll mean giving them more control of (and tighter accountability for) the mechanisms and the money; they’ll need a lot more development too, internally and in the way that they deal with the rest of the service.

Perhaps too, you should think of simplifying the fog of micromanagement and punitive regulation that has descended over the NHS? At a local NHS acute Trust for instance, the 200 pages of specific measures that have to be discussed at every Quality and Safety committee bring its members to their knees. Most clinicians have a positive intent, and are prepared to have their effectiveness measured, but to do it in such prosaic, reductive ways is not only counterproductive in the short term (the measures aren’t usually helpful) but in the long term too (they de-professionalise the workforce). A few outcome measures, measured by peers and patients, would pass the responsibility and ‘ownership’ of the service back to those who are best placed to run clinical services.

Another (albeit more difficult) objective would be to resist the pressure from the acute sector; crises are always more interesting and newsworthy than chronic and often insoluble problems, but they divert attention from what is truly important to what is often merely urgent. To achieve such an objective would be countercultural in today’s world of instant gratification, but if we don’t manage to stem this tide even a little, then the future of a sustainable service is bleak.

On a more positive note, almost everyone in the NHS (and most members of the public) are aware of these issues in some way, and would be willing to throw their weight behind policies that begin to address them. Sure, the traditional tribalism of the different parts of the service will always exercise us, but there is nothing like common purpose to bring people together, and there is plenty of that where the NHS is concerned.

It’s a daunting task, that will need stamina as well as a thick skin; but modernising health services is a worthy end, and we’ll all help where we can.

Good luck, and kind regards

Jonathan

CCGs need to evolve and mature, NOW!

I have writEvolutionten before about the difference between ‘unconscious incompetence’ and ‘conscious incompetence’, and how one has to recognise a deficiency before one can address it, but I have rarely seen such an acute example as the one that currently exists in the CCG world.

As new organisations, often incorporating senior GPs with little if any experience of strategic leadership, it is perhaps not surprising that CCGs have taken time to grasp the breadth and the depth of the issues that face them; not only are they notionally responsible for an annual budget of over £60 billion of public money, they have to ensure that their own primary care house is in order, and deliver a degree of corporacy amongst their members that has never even been envisaged, never mind achieved.

However, now that they are nine months into their first ‘live’ year, one might have hoped to see more recognition of these issues, and a wealth of initiatives both locally and nationally to try to jolt the young groups into a maturity that admittedly needs to be well beyond their years. It is disappointing therefore to note that (certainly in my universe), there appears to be little if anything happening at a systemic level. The Leadership Academy seems intent on setting up a production line to manufacture senior leaders (an oxymoronic concept if ever there was one), and attracting mainly managers from provider organisations.

Others that might be expected to be compiling effective, accessible programmes to fast track CCG development (NHS Confed? BMA? RCGP? NHS Clinical Commissioners?) seem at best merely to be considering setting up such initiatives. They appear to be more concerned with meeting DH/NHS England operational edicts and maximising contractual benefits, beginning to replicate what CCGs were intended to end once and for all: doing things right at the expense of doing the right things.

In the meantime, NHS England, in its unreconstructed macho fashion, is starting to exert more direct pressure in the only language that its political masters seem able to understand: reductive operational targets. The whole notion of culture change and clinically led progress is rapidly being diluted, to be replaced by structures that will look more and more like PCTs, or the even older Health Authorities.

So what is required? The first thing is for CCGs themselves to recognise the need for internal development; even in my own small way, I have been trying to encourage the development of locally focused leadership programmes, learning sets, even stand alone workshops for CCG staff and their members to start to get to grips with the agenda, but it is proving to be a steeply uphill task. CCG chairs and accountable officers should think about resourcing such work themselves, as large scale mass produced products can never achieve the kind of cultural and organizational ‘fit’ change that a ‘bespoke’ programme can. The larger players (see above) should support and facilitate these local processes, and some central resourcing would be very helpful to oil the wheels and get the show on the road.

Do it now, applying a bit of welly to the process, and progress will be satisfyingly fast; leave it much longer, and those in the rank and file of the CCGs, the GPs who really need to ‘think differently’ to achieve systemic change, will have lost interest and gone back to the day job. Without them, not only will CCGs not succeed, the ‘supply side’ drivers (hospital crises, by and large) that have steered the NHS for so long will come to dominate even more strongly, with the only levers available to control them being the traditional blunt, insensitive, centrally controlled levers that have never really worked.

As the adage has it: ‘if you always do what you’ve always done, you’ll always get what you’ve always got.’ Isn’t it time that CCGs started taking control of their own destinies?

Urgent or important? The CCG imperatives

CoveyI don’t usually have much time for self help books, and much of Stephen Covey’s ‘Seven Habits of Highly Effective People’ is fairly self-evident; it’s not exactly rocket science.

However, his famous ‘urgent/important’ matrix does come to mind when looking at the way in which the NHS operates; indeed, the matrix seems to apply to most public services. It is a pictorial diagram (see above) which essentially divides life’s tasks into four quadrants. These range from those that are not urgent and not important, and should thus be given extremely low priority, like washing the car (pretty obvious really), to those that are both urgent and important, like putting out the chip pan fire, that need to be completed as soon as possible (not too difficult to understand either).

It’s the ones in-between that are more interesting: Covey makes the point that urgency tends to trump importance, so that tasks that are urgent but unimportant are given disproportionate priority over those that are important but not urgent, which are all too often ignored. It may be so in our personal lives, where things done for the sake of appearance are all too often given priority over the things that actually need to get done, and it certainly applies to life in the NHS.

Thus for example, reporting the handling of a patient’s complaint seems to take precedence over the handling of the complaint itself, just as when we were children, keeping our rooms tidy was seen as being more important than playing the interesting games that would get them in a mess in the first place.

Much of this dissonance comes from the issue of power and agenda setting. When we were children, it was our parents who did both, and for CCGs, it seems to be almost everyone else that has the power and drives the agenda: NHS England, the area team as their local incarnation, even the local acute Trusts seem to be able to impose their priorities onto the new clinical commissioners. This has meant that many of the CCGs have been spending the last six months adhering to due process and meeting externally imposed targets –  all of which are urgent – at the expense of maturing as commissioners, and developing their working relationships – all of which are important.

The imbalance of power that leads to this distortion of priorities underpins many relationships (personal as well as in business), but is particularly pronounced in the public sector, where political pressures (often manifested in the media) are expressed as well as financial ones. It is a truism that ‘he who pays the piper calls the tune,’ but when he who pays the piper also lays down the law and feels the need to respond to populist prejudices, then the piper is bound to find it difficult to produce new tunes or even refine the old ones.

In NHS terms, we can see the consequences of this phenomenon in a number of ways; for many CCGs, the urgent daily pressure to meet an endless series of operational targets (mainly financial, but also based on clinical and administrative activity) has subsumed the important task of developing a sustainable strategic approach to the delivery of services. The constant need to tick all the short term boxes puts at risk the underlying purpose of CCGs, which is to get to grips with the commissioning agenda: rationalising the delivery of health services so that the NHS has a chance of coping with the pressures of future demand.

The external pressures are also constraining many CCGs from prioritising their own development in terms of both time and money; many have set up novel management arrangements for their senior teams, but these need developing and honing. Perhaps more importantly, CCGs all need to work with their members to change the whole nature of the relationships between individual GP practices and their CCG, so that they fulfil the promise of marrying local implementation for their individual patients with more strategic planning for entire populations.

Of course, it’s easy to criticize other people’s policies, and the reality is that political and financial imperatives have to be met. So how can the important match the urgent? From my perspective, the answer is for the Centre (NHS England and the area teams) to forge their links with the CCGs based less on micromanaged targets, and more on agreed outcomes. Once a CCG has agreed to deliver some broad, population-based outcome objectives with an appropriate budget, then it should be left to the CCG to manage its operational delivery without its ‘parents’ looking over its shoulder all the time, and telling it to ‘go and tidy your room.’

Whether as maturing teenagers or NHS agencies, the key is to feel that we are acting on what we feel is important, not what we are told by others. If the NHS perpetuates the current situation, where CCGs are all doing what others feel to be urgent, then the future of the new system will be short lived indeed; however, if CCGs are allowed to decide their own set of urgent and important priorities within a broad national framework (and budget), then the system will do what was intended: better care, more locally and efficiently delivered, on a more sustainable basis.

A version of this article first appeared in Pulse on 24 September 2013.

The NHS in 2013: plus ça change…

Just over three years aPlus ca change 1go, ‘Clinical Medicine’ (the journal of the Royal College of Physicians) launched a series of articles in which the history of the National Health Service (NHS) was reviewed, and several eminent commentators surveyed the health- care landscape that was expected to emerge once the dust from the 2010 general election had cleared.

Thus, there were articles by the likes of Mike Farrar, chief executive of the NHS Confederation, Michael Dixon, chairman of the NHS Alliance, and Mark Britnell, from the management consultancy KPMG, as well as contributions covering subjects as diverse as system reform to improve NHS efficiency (Jennifer Dixon), the risks and challenges for a new public health system (John Middleton), the future of patient and public involvement in the NHS (Jo Ellins), the role of the National Institute of Health and Care Excellence (NICE) in assessing new technologies and value for money (Andrew Stevens et al) and the then impending commissioning reforms (Elizabeth Wade).

We are now well into the current round of reforms and, with less than two years until the next general election, it is a good time to review the events of the past three years, and speculate on future possibilities and developments.

Political context

The first thing to say is that the initial White Paper presented by the then Secretary of State, Andrew Lansley, during the summer of 2010 took most commentators by surprise. In the lead-in to the election, it had been observed that there was a basic convergence in policy and even organisational style on both sides of the political divide: the concept of the purchaser/provider split was an integral part of both Labour and Conservative policy; the independence of acute provider trusts was taken as read; and the centrality of primary care in coordinating their local health economies had been generally accepted.

Thus, it was largely assumed that, if a Conservative Government did win the election, its policies would be aimed at tweaking and refining the pre-existing direction of travel, rather than overhauling it radically and, indeed, the tenor of the manifesto of the party gave no hint of major structural changes. Such tweaking could even be interpreted as being helpful in making the NHS increasingly able to resist political change, as the policies of the main parties began to resemble each other, even if only in principle.

In the event, when the Liberal Democrat–Conservative coalition was formed and Andrew Lansley was confirmed as Secretary of State for Health, the coalition White Paper incorporated significant restructuring, and a philosophical ‘decentralisation’ that was seen as almost libertarian in its extent. The key suggestions of the document are detailed in Table 1 at the end of this piece, and now look faintly ironic, even after only three years.

A difficult gestation

As with all White Papers, the document was intended to form the basis of a Parliamentary Bill, but during its gestation, there was perhaps more debate among the various vested interest groups than was the norm; nearly all of these groups, lay as well as professional, opposed parts of it, with the most strident criticisms concerning the transfer of so much of the NHS resource to the control of general practitioners (GPs), the apparent abrogation of their responsibilities by politicians and the intention to allow the NHS to be driven so locally, with the variabilities that that implied. The fact that all the debate was being carried out under the cloud of the ‘Nicholson Challenge’ (a call for the NHS to save up to £20 billion over five years that had been issued in 2009 by Sir David Nicholson, the chief executive of the NHS as a response to the increasing austerity being rolled out across the country) added to the tensions and mutual paranoia being felt both politically and in the service itself.

In hindsight, the outstanding lesson from the launch of the White Paper was less about its content, most of which was more or less in line with the aforementioned direction of travel, than the manner in which it was introduced. The Secretary of State seemed to show a degree of political naivety in his approach to the powerful lobbies with which he had to deal and he introduced a whole raft of structural changes that were both unexpected and unwelcome, as well as perhaps unnecessary to enact the proposed reforms.

Such was the level of ‘noise’ concerning the White Paper that an official ‘pause’ was introduced, during which a Future Forum was convened, led by Professor Steve Field, the outgoing chairman of the Royal College of General Practitioners. Its official brief was to carry out a ‘listening exercise’ to consult widely and to modify the White Paper in line with its findings; to this end, the Forum comprised primary and secondary care members, nurses and Allied Health Profession (AHP) members as well as doctors, managers and representatives from other groups, including various patients associations and the voluntary sector.

The unofficial remit of the Forum was to ensure that the White Paper could be turned into a viable bill, although there were also suggestions that mechanisms were needed to counter the centrifugal force of Lansley’s ideas with some centripetal pressures to maintain parity across the service and behaviours in line with central Government policy.

The Forum met for some months (and, indeed, at the time of writing, has yet to be disbanded) and, although its activities did smooth the edges of the original proposals, some might say it changed their original intent. Enough organisational restructuring was introduced following its interventions, for instance, to obviate completely the promise concerning the ‘radical de-layering and simplification of the number of NHS bodies’. Its findings were incorporated into a revised bill, which was followed by more political wrangling in Parliament before the bill was finally turned into the 2012 Health and Social Care Act, which was fully enacted on 1 April 2013.

The 2013 Health and Social Care Act

Its final intentions and structures include the following, although it is too early to draw any conclusions about their effectiveness.

The major structural changes mainly concern the commissioning or procurement side of the NHS. The primary care trusts (PCTs) that were responsible for commissioning the vast proportion of all care for their local populations have been dissolved and many of their functions devolved into the new clinical commissioning groups (CCGs), which are each headed by a chair (usually a GP) and an accountable officer (AO); some AOs are clinical, whereas others are managerial in their backgrounds.

CCGs hold most of the budget for traditional hospital services and have the responsibility for planning and procuring these services, as well as holding them to account. In this task, they are assisted by the commissioning support units (CSUs), which are able to provide a variety of support tools, including payroll and human resources (HR), information and communications.

The CCGs have two strands of accountability within the system. The services provided within primary care (mainly general practice) are governed by the area teams, each one overseeing several CCGs. The strategic oversight of this, as well as the accountability for hospital services commissioned directly by the CCGs, sits with one of four regional bodies linked to NHS England. Clearly, each is holding responsibility for a large population and needs to develop the notion of locally developed services that are in tune with national policy while also knitting together the various funding and delivery streams that encompass primary care and hospital services to create a seamless and effective service map.

The public health function (traditionally involved in the prevention and health improvement agenda, health protection (including immunisation and screening) and generic service planning) has been split in two, with the mainstream operational services being moved to the control of the local authorities and the more strategic functions that cover larger populations, being housed in a new entity called ‘Public Health England’.

The whole system is intended to sit at some distance from its political masters, to try and insulate them from the public and media pressures that often divert policy from its intended direction. This approach was first tried during the early 1990s, under a previous Conservative government, which created the ‘NHS Executive’, housed in Leeds, in a finally futile attempt to create a similar gap between policy and service delivery.

The basic aims of all the NHS reforms of the past 30 years have been to try to bring into line behaviours and expenditure in the acute sector so that they fit with national policies and budgets. In the current round of changes, the main overt objective for this sector is simple: to ensure that all acute trusts reach the standards necessary to become foundation trusts, or if they cannot, to agree some form of strategic alliance with another organisation, so that together they might reach viability in terms of costs and quality.

However, the current changes, both planned (through the new Act) and unplanned (through crises, such as that in the mid-Staffordshire Foundation Trust) have highlighted a new, and much more significant ‘elephant in the room’, and that is the overall future of the district general hospitals (DGHs). There are several reasons why their future is now in considerable doubt.

Firstly, there is an inexorable move towards increasing specialisation, which average DGHs cannot supply; their budgets and turnover are too small, and their ability to recruit ‘premier league’ super-specialists is limited. As a result, the more ‘high-risk’ illnesses (risk being defined by cost, technical difficulty, infrastructure support, staff availability and even litigation risk) are being referred onto the tertiary ‘super-hospitals’, thus depriving the DGHs of work, income and work-related satisfaction for their high-level staff.

Secondly, there is an equally inexorable move of lower-risk illnesses out of hospitals and into the community, where their treatment might be carried out in less formal surroundings that are generally preferred by patients, by staff who can still deliver excellent care, but perhaps at a lower cost. With the shrinkage of this market too, the core business of the DGHs will become significantly smaller and will threaten their viability unless they change their form or their function dramatically.

Thirdly, there are the issues of scale; in the constant tussle between ‘small is beautiful’ and ‘bigger is better’, the size and complexity of the NHS probably mitigates against the former. Interestingly, there is a clear dissonance between the move towards super-hospitals, and the value placed on local treatment ‘closer to home’, that probably reflects the increasing polarisation of healthcare to these two extremes, which once again puts the future of the DGH in doubt. This tension is not new; as Aneurin Bevan said in April 1946, ‘I would rather be kept alive in the efficient if cold altruism of a large hospital than expire in a gush of warm sympathy in a small one.’ The difference is that the intensive interventions feasible today cannot easily be delivered in a small setting, reinforcing Bevan’s aphorism for the 21st century.

What next?

So what might we expect from the new system?

At a superficial glance, the new organisational structure might appear to be well placed to deliver what its designers wanted. It has attempted to separate the service from its political masters; it has declared a move to ‘localism’ and it will pass control of over two-thirds of the total NHS budgets to the CCGs.

However, there are significant structural issues that look likely to trip the system up. The first concerns the distinctions in funding of primary and secondary care.

Because the two streams are managed separately (hospital funding though the CCGs themselves, primary care through the area teams), there is no certainty that moving services from the acute sector to primary care will free up the resources to complete the transfer. However corporately minded GPs might be, they are unlikely to create extra work for themselves and their teams without the resources to manage this, and that process is entirely separate. As in so many previous rounds of NHS reform, the incentives in the system have not been properly aligned.

In the same way that the new system does not acknowledge the factors that motivate and drive GPs, the continuing emphasis on payment by results (PbR), which is a recipe for increasing activity and not improving results at all, is not helpful. In addition, the movement of the mainstream public health function into local authorities, although it might be appealing at a conceptual level (the drivers that influence the health of the population are largely outside the biomedical universe), the emerging reality seems to comprise mixed interest among local authorities, with some apparently not considering any of the broader determinants of health beyond repairing potholes and running sexually transmitted disease (STD) clinics.

So there are structural problems, but there are even larger and more significant issues in the processes that are now supposed to govern the NHS.

Lansley was probably unduly optimistic in his aspirations to have the NHS driven quite as locally as he intended, but in the intervening months and years that the Bill has evolved and become law, it has created a polarised dynamic between the CCGs at the local end and NHS England at the centre, with the power apparently settling increasingly at the central end. GPs and their PCT colleagues who took up the notion of CCGs are seeing their expectations and aspirations once again diluted and soured, with the result, even at this early stage, that there is already poor morale and reducing engagement.

Processes should not subsume outcomes

Clinical professionals in general, and GPs in particular, are in positions where they can make or break their local heath economy without ever doing anything wrong. Their motivation and enthusiasm are the only way that referrals and admissions might be reduced or prescribing improved and, if their zeal is missing (or worse still, lost), then the auguries for success are poor. Add to that the ‘Nicholson Challenge’ being pressed upon them and one can see the likelihood of short-term ‘fatigue’ in the new system and long-term disaster as new doctors consider their reasons for going into general practice in the first place, and begin to vote with their feet.

One final bit of soothsaying; if the new system was designed to preserve corporate memory while allowing new ideas and ways of thinking to emerge, then even that probably has not worked. As the CCGs and CSUs bed down, not only are they populated largely by staff who had worked in PCTs previously, but their growing ways of working, their modi operandi, also begin to look increasingly controlling, unimaginative and bogged down in ‘due process’. Tendering for service change, allowing experimental models of care, anything that rocks the boat of ‘doing things right’ is being frowned upon, even if it is at the cost of ‘doing the right thing’.

The road to Hell, they say, is paved with good intentions and it is easy to see how an Act designed by a committee that tries to please everyone is almost bound to fail.

In fact, the issues are remediable: if the accountability of the CCGs to NHS England was simplified into one stream based on outcomes rather than on processes, then the incentives for those in the CCGs would be more positive. The oft-cited ‘conflict of interest’ for GPs would be less relevant if they became responsible for delivering all health-care for their population, in any (appropriate) way they chose, ‘sub-contracting’ to others what they didn’t do themselves (and hence maintaining vicarious responsibility).

If the rules governing changes in the acute sector were simplified, and allowed more flexibility of function as well as structure, then some innovative and dynamic solutions to these ‘wicked issues’ would emerge. In addition, if those working in the NHS, especially at senior level, could see something positive about which they could be enthusiastic and in which they could invest their hearts and souls, then I suggest that this might be ‘another fine mess’ we could actually reverse.

Table 1. Summary of main suggestions in the White Paper Equity and excellence: liberating the NHS.

  • Shared decision-making: ‘no decision about me without me’
  • Choice of any provider, consultant-led team, GP practice and treatment
  • Hospitals need to be open about mistakes
  • Stronger voice for patients and the public
  • Focus on outcomes and quality standards. Reduced mortality and morbidity, increased safety and improved patient experience and outcomes
  • No targets without clinical justification
  • A culture that puts patient safety above all else
  • Money to follow patients across the NHS to promote quality, efficiency and choice
  • Providers to be paid according to performance based on outcomes, not just activity
  • Professionals and providers to have more autonomy and accountability
  • Greater freedoms and less political micromanagement; ministerial powers over routine decisions to be limited
  • Devolution of power and responsibility for commissioning to GPs and their practice teams working in consortia
  • More connection between local NHS services, social care and health improvement
  • An independent NHS Commissioning Board to lead on the following: achieving health outcomes, allocating and accounting for resources, quality improvement and patient involvement
  • All NHS trusts to become, or be part of, a foundation trust
  • Monitor to become an economic regulator, promoting effective and efficient provision, competition, regulating prices and safeguarding continuity of services
  • Enhanced role for the Care Quality Commission as a quality inspectorate across health and social care
  • Ring-fenced public health budgets, reflecting population health issues, with ‘premiums’ to reduce health inequalities
  • £20 billion efficiency savings by 2014,to be used to improve quality and outcomes
  • NHS management costs to be reduced by more than 45% over the next 4 years
  • Radical de-layering and simplification of a number of NHS bodies
  • Debate on health should no longer be about structures and processes, but about priorities and progress in health improvement for all
  • Implementation to be bottom up

This piece is based on an article published in Clinical Medicine in August 2013: 2013, Vol 13, No 4: 374–7

CCG: friend or foe?

Friend or foe1Put yourself for a moment into the shoes of a GP; not an ambitious, management focused, media hungry go-getter, but a doctor who wants the best for his/her patients. Your list size is average, which means that around 1600 patients are registered with you, and depend on you to co-ordinate their care, and be their first point of contact, their main provider of care.

Do you happen to know how much the NHS spends on an average GP list each year? Using the back of an envelope (so the figures are approximate), I worked out that  in 2012, the UK NHS budget was close to £110 billion, which was available to look after about 60 million people; that works out at about £1800 for each person, which meant that for an average list, about £2.9 million was available. Scary isn’t it?

Now obviously, quite a lot of this was spent on fixed overheads like Public Health England, and redundancy packages for displaced managers, but let’s ignore these for the moment, because it’s always been the Government and ‘The Centre’ that have determined these. The important point is that since April this year, control of over two thirds of this budget has been handed over to CCGs, to spend on commissioning services for their patients.

The logic underpinning this move has been explicit since the 1990s: GPs co-ordinate their patients’ care, and their referral of these patients determines much of the activity in the community, mental health and acute sectors; so who better than these individuals to ‘own’ the resources associated with all this activity, and use their knowledge, common sense and autonomous professionalism to begin to move activity in ways that improve both the effectiveness and the efficiency of that care?

All the reforms of the past two decades or more have been moving towards this end. GP fundholding, GP commissioning, PCGs, PCTs, and now CCGs, all have been designed to wrest control of activity as much from politicians as from the large provider organisations, to stop them peddling their vested interests to the public (often through the tabloid media).

The logic of all the policies developed over this time (Working for Patients; ‘a primary care led NHS’, ‘the New NHS-modern, dependable’; Equity and Excellence: Liberating the NHS; to list but a few of the buzz phrases) have all been pushing in the same direction, albeit with different structures in place to make the policies happen.

So how does this link to the title of this piece? Are CCGs a Good Thing for GPs, or a Terrible Disaster? I started by pointing out that in theory, GPs each have the power to control the manner in which £2 million pounds or more should be spent on the care of their patients, so I’ll follow that up with two challenges.  The first is: who do you think better understands patient flows and needs: patients’ GPs, or middle managers based in whatever incarnation of health authority happens to be in vogue? Only GPs know what their patients’ medical needs really are and with the freedom to be innovative, they could probably think of all sorts of ways of doing things better, more quickly, in more user-friendly ways: it’s £2 million pounds, for goodness sake…

But my contrary second challenge is about strategy: £2 million may seem like  a lot to you and me, but it’s only a couple of trees in the enormous woods of the NHS; how do we a) maximise its impact and b) minimise the risks to individual GPs, their practices, and their patients? The strength of general practice lies in individual patient care.  If GPs are to be involved in planning and procuring services for entire lists, then they will need ways of working that offer economy of scale and provide insurance against unexpected events (imagine what a cluster of motorway crashes over a holiday weekend would do to the Trauma & Orthopaedics budget) without destroying the ‘can do’ spirit that has been so integral to their success over the past 65 years.

Where CCGs are genuinely ‘owned’ by their GPs, then the new organisations have great potential.  As in any successful corporate entity, individuals will need to accept that the needs of the group will sometimes trump their own local issues, and they will have to toe the corporate line a lot more often than they may have done in the past. However, they should then expect their CCG ‘corporation’ to offer support and act on practical suggestions often enough to show the practices overall benefit and maintain their loyalty. They could then be seen as ‘friends with teeth’, where the relationship needs constant effort and development, but where the gain (whether in terms of patient care, professional satisfaction, or even primary care development) justifies the pain.

However, if CCGs are either run in a top down fashion, or driven by political rather than care based priorities, then it will not take long for the cynicism to emerge; like the PCTs before them, such CCGs will quickly be seen as foe, whose actions are to be resisted and subverted.

In summary then, CCGs have the potential to be THE agent for change in the new world of NHS England, but only if their growth and development are carefully nurtured. The large scale leadership developments that seem to be emerging from the new Leadership Academy have never worked before, so it is hard to see how they will be more likely to succeed this time. What is needed is enough interest to be engendered amongst ‘working’ GPs to persuade them to invest some of their precious time and emotional energy in getting their show on the road, and make it a show of which they, and the entire NHS, can be proud.

And that won’t happen without effort or resources; but with the potential for every GP with an average list to really influence how £2 million is spent on his or her patients, isn’t that investment worth it?

This piece is based on an article first published in Pulse magazine on 24 June 2013

If you go down to the A&E, there shouldn’t be any surprise….

Teddy bearsOur increasing use of hospital services is out of control and unsustainable, and is contributing to the current crisis in accident and emergency (A&E). But the problem isn’t new and 30 years of NHS reforms have tried – and failed – to control it.

We now have figures that show a million more people went to A&E in England between February 2012 and January 2013 than had done the previous year – although changes in reporting may explain some of the increases we’ve seen in the past 25 years. There are also reports that trolley times are routinely reaching 12 hours in some parts of the country.

Now that GPs have been given control of some £80bn to plan and pay for NHS services (it’s what Clinical Commissioning Groups are for…),  many believe they should also be able to treat as many as 30% of people who come to A&E, more appropriately, and in a way that eases the burden.

The 1990s saw the creation of the ‘purchaser/provider split’, which separated those who planned and bought services from those who provided them – i.e mainly the health authorities and hospital trusts. With this came the half-hearted introduction of some elements of competition.

But only if we properly understand the underlying issues can we develop a coherent strategy to deal with them. And these issues can be encapsulated in three words: poorly aligned incentives.

A question of supply and demand

The dynamic between supply and demand drives many aspects of the human condition, and this applies to the NHS too. It has always been demand led, as it was created to respond to and meet our health needs.

There are elements of preventative care, but they’ve never been as prominent as ‘sexy’ acute services such as saving babies or heart transplants.

However, demand for any service is based on knowledge of that service, and in healthcare (as elsewhere), this kind of intelligence lies mainly with those who provide them, who use it to drum up business. Until we knew that 3D televisions existed, we didn’t realise how much we needed one. Similarly, in the NHS, until we know that treatments are available for heart disease/depression/impotence, we don’t ask for them.

As in every other industry, the supply of health services tends to drive demand. Hospital funding has moved away from opaque ‘block contracts’ – crudely, an annual allocated amount – to a system based on ‘payments by results’. As this is actually payment for activity, it tempts hospitals to increase supply to drive up demand.

In commercial industry, demand is largely regulated by price: “I’d love that 3D telly, but I can’t afford it right now”. But NHS services are largely free for us to use.

They are also free to GPs, who control most of our access to hospitals through patient referrals – except A&E of course, where we decide whether or not to visit.

Traditionally, GPs referred cases to their hospital consultant colleagues that were complex, or needed high-tech interventions. It’s always been assumed that referrals are driven purely by clinical criteria (what patients need) and specific skills (of a particular hospital specialist), not serendipity or whimsy. Patients’ needs and clinicians’ expertise are supposed to matter – not consumer choice or doctors’ golfing schedules.

However, if the balance between supply and demand has depended on these assumptions, they have been eroded over the years; it’s been assumed that patients seek help when they need it (though the tension between ‘need’ and ‘want’ increases as we’re encouraged to become consumers of a ‘free good’ like the NHS); we’ve also assumed that hospitals respond to demand (and are not incentivised to increase it) and that GPs are professionally driven only to refer patients when there is an absolute need.

But with GPs’  contracts now based largely on listed activities,  they are less prepared to absorb the grey areas where no explicit activities or payments are described – for example a home visit to a bereaved widow.

Apply these criteria to the A&E situation and the results are obvious:

  • Patients, now consumers used to instantaneous service in other aspects of their lives, are bound to prefer going to A&E than waiting for an appointment with their GP. Not only is A&E open 24/7 but tests that would take weeks to arrange through normal channels are instantly available. Sure, the care is neither continuous or holistic in A&E, but these concepts have been increasingly devalued because they are so hard to measure.
  • Hospitals receive payment for every attendance at A&E, and get addiitonal sums if patients are then admitted to the wards. They are also punished for keeping patients in A&E for more than four hours, so admitting patients becomes a no-brainer. It’s only now, when demand for hospital services is starting to outstrip supply – and the cash to feed it – that the cracks in the system are beginning to show.
  • If there are no disincentives for GPs to refer patients into hospital then why wouldn’t they do it, when they feel disenfranchised and de-professionalised by the reforms that have been churning round them for three decades?

This is all easy to analyse, but harder to repair. The basic precept underpinning the NHS has been that it’s free at the point of delivery, so the mismatch between consumerism and the welfare state is bound to expand, unless the notion of corporate responsibility in health can be re-introduced or until services cease to be free.

One mooted idea has been to increase public awareness of NHS costs, on the basis that this might make them think twice before (ab)using the ‘free’ service.

Activity-based hospital funding isn’t sustainable, and a return to some kind of risk sharing between service providers and those who commission services (the GPs) is a prerequisite to managing demand at an institutional level.

GPs’ incentives must be better aligned so that it becomes truly in their interest (professionally and morally, as well as financially) to restrict referrals to those that are really necessary.

The biggest issue is that of managing service availability; as long as we increase the supply of hospital services (particularly in A&E departments) this will feed demand. We have responded to the supply side constraints in clinics and investigation facilities by increasing that supply, so it is hardly surprising that this has in its turn encouraged higher demand.

The obvious corollary would be to deliberately restrict services, but that would be very hard to sell politically to an already disillusioned electorate. However, if GPs and the CCGs were allowed to do what they were first intended to do, their core purpose would be to extract the optimum health benefit from the public funds allocated to NHS Trusts.

Managing demand would be high on their list, and most of them would tell you that given the right tools, they would manage to do this in a much more coherent fashion, albeit at the cost of reduced health consumerism. The challenge is to loosen the stranglehold from central government sufficiently to allow this to happen before all the breath of enthusiasm for doing anything is completely cut off. And that really is a Political decision.

This is a modified version of an article published in ‘The Conversation’ under the title of ‘A&E is in crisis because we all take it for granted.’ That piece is available to view at http://tinyurl.com/mp8esp6

A snack that you can eat between blogs without ruining your appetite

I’ve been very busy this week, and haven’t had the time to do a full length entry.

However, I was involved in an interview with The Consultant magazine, part of a feature that they were running on commissioning.

The link to the magazine is: http://tinyurl.com/o25jxmo, and it may be worth a look.

Hopefully, I’ll be back on track in the next few days with a full blown article here.

Making CCGs work: three cardinal rules

jigsawClinical commissioning has arrived, but it will take a while before it becomes clear whether it is creating order or chaos. Now may be an appropriate time to revisit the underlying principles to see how it is likely to pan out.

Commissioning is not a simple notion, but an inclusive concept that covers a number of different functions. At the ‘micro’ level, there is the direct procurement of individual services, a process that has been called contracting: the customer pays the supplier for a service on which they agree.

Let’s say the customer is a home-owner, who wants a new kitchen; he has a rough idea of what he wants (the ‘output specification’, if you like) but as he doesn’t know much about building kitchens, he will need to capitalize on the supplier’s expertise and trust him to do the job well. Success will be measured in terms of overall quality and satisfaction, timeliness, and costs, and if these aren’t met, the buyer may have to use the contract to hold the supplier to account, and gain redress for any failure.

In NHS terms, such micro-commissioning is based on GPs’ referral decisions: GPs know roughly what they want, and they have a knowledge of the local expertise; their role is to organize specific procedures with the appropriate experts, and then check that they been carried out to the agreed specification.

They have the advantage over the home-owner that their knowledge of specialist provision, whilst not encyclopedic, is detailed enough to let them make realistic assessments of quality and perception, timeliness, and costs.

At this level, one would not expect the home-owner or the GP to make decisions based on strategic impact or links to a European Directive; it would be for the specialist expert in each case to keep their customers apprised of any legal issues, and it would be the experts who would be held responsible for any non-compliance.

At the ‘macro’ level, the parallel relationship may be that between the town planners and a major home-builder; as with the individual kitchen, there needs to be agreement based on a mutual understanding of the outcome of the job, and any necessary markers of its progress.

Thus, the planners may want the new estate to be carbon neutral, to fit into the existing architectural ‘mood’, and to be completed within a certain time, to a specified quality, at an agreed cost; if they are sensible, they will leave it to the technical experts to decide the precise manner in which they respond to these specifications. Not only does that involve the builders in the decision-making and so keep them engaged and enthusiastic, it also maximizes the benefits of their expertise and promotes a degree of risk-sharing that divides up the responsibility (legal, financial, perceptual) for the project, and ensures that both parties need to attain the same positive outcome to be satisfied.

Back in the NHS, this relationship mirrors that between strategic commissioners (the CCGs, Area Teams, and the regional offices of NHS England: do we really need all three???) and the acute sector pretty well. Like the town planners, the strategic commissioners will need to incorporate national policies and regulations into their strategies. They will need enough knowledge to ensure that their providers are not pulling the wool over their eyes, without getting bogged down in the level of operational detail that boomerangs the risks back to them whilst raising the transaction costs of the whole process.

At this level, the quantum being procured is much larger, and so it is harder to ‘contest;’ a local authority, having agreed for a contractor to build them a whole new housing estate, would find it much more complex to withdraw from their contract than if they were contracting for a single kitchen. However, a competent authority should have levers to pull, should the builders not fulfill their side of the agreement.

And it is here that we come to the nub of whether or not commissioning in the NHS will succeed.

While developing and monitoring contracts (like any other performance management system) should be based on the carrots of success, it should be backed up by sanctions that are appropriate and viable.

Such levers should ultimately be based on the ability and feasibility of withdrawing the contract, something that itself depends on the availability of alternative provision and the consequences of such action (be they financial, legal, and perceptual, with the added complexity of how they affect the health of the population involved).

When the notion of commissioning first appeared the NHS in 1990 in the guise of the ‘purchaser/provider split’, its main purpose was to steer the acute sector away from fuelling ‘supply-led demand’ in health services and towards a new responsiveness to the needs of the population.

In fact, several iterations of change have not really had major impact on the acute sector, which still seems to be relatively unaffected by the current organizational changes, although it is facing some highly challenging financial pressures.

As long as it remains impractical to offer real challenge to the acute sector, commissioning will be largely irrelevant, offering no more than minor political irritation to the vast and politically-aware acute sector.

The three key challenges for the new commissioners may be summarised as follows:

– At the micro-level, the development of more widespread alternatives for GP referrals needs to be encouraged; merely shifting referrals between different hospitals won’t be enough, as the ensuing Brownian motion is unlikely to promote any real change, just random movement.

What is required is the threat of removing activity from the sector entirely, which will depend either on practices being allowed to develop viable alternatives themselves, or other providers (private or otherwise) being given access to such provision.

– At the macro-level, the systems being developed (whether through contracts or other less tangible ‘currencies’) must not be allowed to become ‘too big to fail’. Keeping the quantum of exchange small enough to allow real contestability is going to be key if commissioning is to become an effective management philosophy.

Thus for example, it is much easier to challenge the provision of a single service (Physiotherapy? Pathology? Plastic surgery?) where real service delivery changes may be seen, than in trying to shut down an entire hospital, or even parachuting a new management team into a failing Trust, where direct patient care is unlikely to be affected (at least in the short term).

– And at the ‘meso’ level that spans micro and macro, it will be vital that the consequences of any actions be seen quickly and directly. If the GPs in a CCG want to repatriate a service out of the acute sector and into the community and it takes three years and a warehouse-full of bureaucracy to do it, then the GPs will simply give up trying. The links between input and effect need to be obvious and the accountability for both needs to be transparent and appropriate.

If commissioning becomes an ineffectual brake on demand, then we may as well abandon the whole concept now; however, if we manage these cultural changes, then the introduction of the new commissioning arrangements have the potential to be the ‘pivot point’ for changing the entire dynamic of the NHS.

A version of this article was published in Pulse magazine in the UK on 8 May 2013