Sara Bainbridge gives an understanding of clinical commissioning and explores its changing face through new policies, systems and legislation.
For anyone involved with the NHS in England, 2019 started with New Year’s Resolutions and a Long Term Plan. This set out some new priorities, restated old ones and provided some clarity for clinical commissioners.
Moving towards a more collaborative way of working – with ‘systems’ bringing together providers and commissioners – had been a theme of health policy since the advent of Sustainability and Transformation Partnerships in 2015. Through various iterations (and acronyms), it’s now clear that this approach is here to stay, as the NHS Long Term Plan set out that all of England will be covered by Integrated Care Systems (ICSs) by April 2021.
“As they get bigger, clinical commissioning groups are conscious they need to retain their local relationships and understanding”
This has implications for clinical commissioning groups (CCGs) – the local planners and purchasers of healthcare – as the Long Term Plan suggested there would be ‘typically’ one CCG for each ICS. Although we don’t know the final number of ICSs, nor how ‘typically’ will be applied, this does mean there are likely to be far fewer CCGs in 2021 than the 191 there are now.
Now we’re halfway through the year, further publications have emerged which steer clinical commissioners further along the integration journey. NHS England and NHS Improvement, now a single organisation, published their proposals for legislative changes in the spring. These aim to overcome barriers to integrated working which CCGs and their provider counterparts might experience – amending the Health and Social Care Act to try to reduce the burden of procurement, share responsibility for health outcomes with other partners in a system, reform payment approaches and create joint decision-making committees, amongst other things.
Clinical commissioners are generally supportive of these changes as many of them reflect the issues they raised with us as the barriers to integrating. But changing legislation takes time and has no guarantees so efforts must continue to support CCGs to work collaboratively – which NHS England and Improvement (NHSE/I) have been doing through publications such as ‘Mechanisms for Collaboration’.
As mentioned, the recommendation for ‘typically’ one CCG per ICS still leaves some room for interpretation. But some CCGs are already taking steps to work at a larger scale – with many adopting joint working arrangements (as many share accountable officers) and discussing merging. NHS England published new guidance in April* for CCGs thinking about a formal merger. Any CCGs wishing to merge at the start of the next financial year would need their application to be approved by the national bodies in September.
But as they get bigger, CCGs are conscious that they need to retain their local relationships and understanding. Keeping in touch with their constituent ‘places’ or ‘localities’ is an important consideration for them and their local government partners, who often operate at this geographical level. Becoming the same size as an ICS might not be the best option for some CCGs so this recommendation must allow some flexibility.
More locally, Primary Care Networks are another new opportunity to fundamentally change the way healthcare is provided. They are set to cover the whole country in 2019, working at ‘neighbourhood’ level – for populations of around 50,000 people. They are being commissioned and approved by CCGs over the summer and will facilitate more multi-disciplinary team working between community and primary care.
Times of change
What does this mean for those trying to get their heads around clinical commissioning? There is a lot of change, but it should be building on what has come before in terms of collaboration and joint working with local government and providers. CCGs are likely to reduce in number, working differently: for a larger population and more strategically. Going through mergers is the next step for many but will mean they have to develop new organisations in parallel with getting on with the day job.
Ensuring all parts of their population can have the best opportunity for good health outcomes means they will continue to be making their crucial and often difficult decisions. Making these decisions should happen at the level that is most appropriate – at neighbourhood, place or system level – but will still be made by clinical leaders and with the perspective of trying to get the best value from the NHS pound. Although the Long Term Plan came with a welcome injection of funds, there is still limited investment available for a growing and ageing population, so CCGs will be continuing to think about how to improve efficiency and manage the health of their whole population effectively.
This means NHS Clinical Commissioners’ work supporting CCGs to achieve best value will continue – we’ve worked with NHS England as part of its medicines value work, including consultations and guidance on items which should not be routinely prescribed in primary care and conditions for which over-the-counter items should not routinely be prescribed. We also know that CCGs struggle with growing spend on medicines and will, therefore, be advocating on their behalf on these issues.
The second half of 2019 is unlikely to see things calm down, as we could see draft legislation, each ICS publishing five-year implementation plans, and CCGs applying to merge. This comes alongside several anticipated set pieces from Government – a prevention green paper, the social care green paper and a spending review that should include a settlement for local government – all of which will heavily impact on CCGs and their work with others across health and care.
Sara Bainbridge is Head of Policy and Delivery at NHS Clinical Commissioners.
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