Comment

A balancing act: commissioning in the new world of accountable care

Ruth Robertson, policy fellow at the King’s Fund, considers how CCG responsibilities and relationships will change and evolve as the NHS moves towards integrated structures of care.

Adapting to change is part of business as usual for the NHS, as policymakers have repeatedly restructured the health commissioning sector over the last 20 years. This culminated in the Health and Social Care Act 2012, which introduced what were arguably the biggest reforms in the health service’s history, creating GP-led CCGs.

The past few years have seen a pause in this cycle of top-down reorganisation. Since the NHS Five Year Forward View (FYFV) was published in 2014, the focus of reform has shifted from commissioners and competition to providers and collaboration. The FYFV bases the health service’s future on developing new, locally-designed integrated models for providing health and care.

In line with this, we are starting to see new accountable care organisations (ACOs) emerging across England. These are providers or groups of providers that collaborate to provide care for a defined population – this might include primary, community and acute care. ACOs are often funded via a multi-year contract that defines outcomes and other objectives to be delivered within an agreed budget.

A changing landscape

There is now a clear (and some might say purposeful) gap in the policy landscape. How will CCGs be affected as these new models of care develop? How will they work with sustainability and transformation partnerships (STPs) – regional planning groups made up of commissioners and providers tasked with securing financial stability and supporting the development of new models of care? And how will they work with accountable care systems (evolved versions of these local planning structures) that are being layered on top of an already complex NHS landscape?

According to health secretary Jeremy Hunt, this new world fundamentally changes the incentive structures in the NHS: “…In many ways these models weaken the ‘internal market’, or purchaser-provider split, to allow integrated and joined-up care. We want to encourage this because it will improve the quality of care, meaning less resources are used up in complex contract negotiations.”

Simon Stevens, chief executive of NHS England, went further, saying the purchaser-provider split will effectively end.

What the future holds

Despite what looks like a major change in policy, little detail has surfaced about what this means for commissioners. Policy documents have either not appeared or include just a few lines on what the future might look like. The future of commissioning organisations has been left for local areas to decide, which brings both opportunities and challenges.

Three key themes are likely to characterise the development of commissioning over the next few years:

• Collaboration: CCGs are already working closely with their neighbours by sharing staff, setting up joint committees/governance structures or merging. This trend will continue as CCGs align more closely with their STP footprint, as will the trend for closer collaboration between CCGs and local authorities to integrate health and care commissioning. Add to that more collaboration with providers to jointly plan local services through STPs and ACOs, and it’s clear that skills in developing and managing relationships and leading change across systems will be more important than ever over the next few years;
• Delegation: This includes delegation within the commissioning system – since 2013 NHS England has delegated new responsibilities for general practice and some specialised services to CCGs, with more planned – and delegation out of the commissioning system. As new models of care develop, some CCGs are likely to take on a more strategic commissioning role, delegating some of their functions to groups of providers or ACOs, with whom they will agree a large capitated contract that leaves the provider responsible for much of the ‘operational commissioning’ required to deliver it. These changes affect the skillsets needed within CCGs and may require some staff to move between organisations;
• Variation: As local areas forge their own paths, commissioning is likely to look increasingly different in different parts of the country – with some places running full steam ahead towards a more strategic model, while others maintain structures and roles similar to those they have today. Even the most go-ahead CCGs will need to play different roles depending on which organisation they are commissioning from. They may be a ‘strategic commissioner’ when interacting with a large local ACO and an ‘operational commissioner’ when commissioning other services. This creates challenges for CCGs (simultaneously fulfilling multiple roles) and regulators (who will need to define what good looks like in a varied system).

Beyond these developments, the big system changes (like the blurring of purchaser-provider split and the development of ACOs) present some quite profound questions about the role of commissioners. Do we still need commissioning organisations in this more integrated system? What is possible within our current legal framework? What does being more strategic mean in practice? How can the centre hold integrated local systems to account for their performance?

A balancing act

With such fundamental issues in play, leaving the vision for commissioning to local areas may not be sustainable over the long term. However, NHS England faces a challenging balancing act.

On the one hand, encouraging local experimentation and evolution will generate novel solutions, garner local ownership and allow each area to build on its strengths.

On the other, without a certain amount of central direction some areas will fall further behind (particularly those where collaboration and transformation have been difficult in the past) and effort will be duplicated as many local areas grapple with the same fundamental questions.

As CCGs and STPs look to take major strategic decisions about the future shape of commissioning and provision locally, there is, as yet, no one clear answer to what a high-performing planning function should look like in the context of new models of care. NHS England and CCGs across the country will be watching frontrunners in areas like Manchester, Croydon and Dorset to see whether the reforms they are making to their local health systems are models that others can follow.

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W: www.kingsfund.org.uk