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

Cake

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).

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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