Patient Populations - Don't force PCT size on commissioners

We might be going insane delivering the current NHS reform agenda, says Scott McKenzie.

Map showing 257 clinical commissioning groups (CCGs); colour denotes NHS region (Image:
Map showing 257 clinical commissioning groups (CCGs); colour denotes NHS region (Image:

Insanity: doing the same thing over and over again and expecting different results. Does this appear to be exactly what is happening with the NHS reform agenda?

PCTs have grouped together to become PCT clusters, SHAs are heading in the same direction, both with little more than tokenism towards emerging clinical commissioning groups (CCGs), because the behavioural changes required to deliver ground-upwards change simply have not materialised, in the main owing to confused messages and lack of direction.

Work like a PCT
The favoured message at ground level is rapidly becoming 'CCGs can only work if they work like a PCT'. Small CCGs will fail because they are not big enough to manage risk, or large enough to purchase the support they require. CCGs will end up with more of the same from above and simply revisit the world of frustration, bureaucracy and inefficiency that was bestowed on them by practice-based commissioning.

Risk is not managed by size alone; it needs a careful process of understanding how and why practices consume resources. It then requires a risk pool which practices can access when the individual patient 'invoice' exceeds the agreed limit. We are currently working with CCGs on a limit of £7,500 (beyond that point for a single episode of care, the risk pool pays out), with excellent results.

Practices have accepted the process, because they now understand that not everything happening in the budget bottom line is down to them. This has opened up a new way of engaging practices and demonstrating the value of being a member of a CCG of likeminded practices. It has also demonstrated that many things are within the control of the practice. This is slowly leading to the level of change required in each practice concerning referrals, emergency admissions and prescribing, in return for help, support and encouragement from the CCG. The risk pool approach could be shared by many CCGs; size is no barrier.

This risk pool does not, as yet, cover the frequent flyer patient type, with 'invoices' of thousands of pounds for numerous attendances. This remains with the practices and CCGs, with many now looking for innovative solutions to an old problem.

We are also working with CCGs to explore innovative ways of dealing with this.

Our evidence shows the best results are coming in smaller CCGs (we support CCGs of 45,000-500,000 patients), simply because engagement is easier to drive and there is transparency for every practice. Our evidence from larger CCGs is that engagement at practice level is the most difficult part. This may be based on the ability to apply peer pressure to attend meetings, and to act on evidence presented, or the work required to deliver the outcomes.

In larger CCGs, we often find practices trying to hide by avoiding meetings, having little engagement with the process and hoping nobody will notice, or that if they do, it will not be acted on. There are simple ways to handle the question of size, yet these are not being properly exploited.

Scott McKenzie: 'The best results are coming in smaller CCGs, because engagement is easier to drive and there is transparency' (Photograph: Author Image)

Turning to the ability to purchase support, there is evidence to counter arguments concerning not being large enough. In the commercial world, it is not uncommon to outsource work that would be impractical or not cost-effective to deliver in-house. Outsourcing will be a key test for emerging commissioning support service (CSS) providers within PCT clusters.

There is an exciting opportunity to look at what support needs to sit within a CCG and what could be outsourced to a CSS. Some PCT clusters see this as an opportunity and a threat, in equal measure. The opportunity is there for those who can make the leap of faith that delivering the required behavioural change will secure them the long-term contracts to support CCGs. Equally, those clinging to the same mindset and behaviours might find themselves at most risk, particularly if one or two CSSs make the change and start to deliver; they will become an attractive proposition for other CCGs to buy from. Throw in some private sector providers and the risk for those unwilling to change increases further.

US businessman Warren Buffett has the perfect quote for where the NHS reform agenda currently stands: 'Should you find yourself in a chronically leaking boat, energy devoted to changing vessels is likely to be more productive than energy devoted to patching leaks.'

What we do not yet know is whether the leaks are permanent and the DoH will force PCT clusters to develop a new vessel, or whether they will provide one large patch for all leaks, much as it will be temporary. Without the change required, the NHS is going to find itself back with the same problem that the reform agenda set out to tackle.

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