This article explores the many forces already creating turbulence for those involved in commissioning, and particularly GPs, whose work is the focus of our research at the Nuffield Trust.
Relationships with providers evolving
The Five Year Forward View, published in October 2014, has restarted the conversation about where the boundaries should lie between commissioners and providers. Large, integrated providers could absorb some CCG functions around demand management and service redesign, leaving smaller-scale CCGs to monitor outcomes and provide quality assurance.
The idea is that providers could be better placed to make decisions regarding service provision and it would potentially give them more ownership over any changes they implement. However, one risk with this approach is that these young organisations may struggle to undertake activities that CCGs are still perfecting after three years in operation.
CCGs between a rock and a hard place
CCGs will undoubtedly take on more responsibilities from NHS England: primary care, specialised services and pharmacy. In fact, our research suggests that some CCGs have always felt as though they were performing some of the duties originally conceived as being held by NHS England, as a result of NHS England’s lack of capacity at a regional level.
Although this is presented as a choice for CCGs, a recent letter from NHS England encouraged all CCGs to move towards full delegation of primary care commissioning. This is despite anecdotal evidence that extra support for CCGs pledged by NHS England to support groups with these additional responsibilities has not been forthcoming. This puts CCGs in a difficult position.
Some CCGs will have already adopted, or be thinking about, commissioning across a whole pathway for a certain condition – an example of which is cancer and end-of-life care in Staffordshire, which spans four CCGs, two local authorities, two national bodies and the voluntary and community sector.
But this single-condition approach could be out of step with the ‘place based’ vision of joined-up health and social care in the Five Year Forward View. Reconciling the two may add yet further confusion to already stretched commissioning systems.
Devolution of local health services
The Cities and Devolution Bill now progressing through Parliament will allow local areas to unify budgets between health and other services and could, in theory, allow an area to remove their CCGs and transfer responsibilities to the central local body.
Even without the removal of CCGs, it is not clear where accountability would lie, or how and with what legitimacy NHS England could regulate and assure the spending of health budgets in these arrangements.
The Cities and Devolution Bill is one to follow closely – the future of commissioning and CCGs may depend on its outcome.
The end of clinical commissioning?
Commissioning seems to be one of the areas of the NHS in perpetual change – a fact which may finally have pushed clinical commissioners a step too far.
Entrepreneurial GPs who have been adding their voice to commissioning for over 20 years are beginning to turn their backs on the NHS's formal structures and instead put their energy into developing their own provider organisations.
Research we published earlier this year with The King’s Fund suggested that, despite the emphasis in the Health and Social Care Act on handing power from managers to GPs, many felt that influence over decision-making remained with CCG managers. Initial enthusiasm and engagement in the CCG was beginning to wane, and we do not expect the trend to have improved over recent months.
The future options for CCGs listed above will undoubtedly make the day job harder, not easier. The increased opportunities for conflicts of interest brought about by primary care co-commissioning, for example, have left some GPs feeling exposed to high levels of risk.
New local partnerships required
Delivering the integrated health and social care system promised by 2020 in the Spending Review will require a myriad of new local partnerships and this could risk taking decision-making even further away from clinicians.
So what does all this mean? This is not the imminent end of CCGs as we know them. Change is slow and, in some areas, the CCG will remain the most influential organisation locally with a strong clinical presence.
However, in those areas where power and control is shifted to the providers or to larger commissioning organisations, it’s vital that as these changes unfold, the collective knowledge that has been accumulated by clinical leaders is not lost amid yet another reorganisation.