Health Service Focus


The best CCGs should be the ‘conductor of the whole orchestra’: the future of specialised commissioning

Source: National Health Executive Nov/Dec 2014

Dr Simon Bowers, GP and vice clinical chair of the Liverpool Clinical Commissioning Group, gives NHE his thoughts on the current landscape for commissioning specialised services. David Stevenson reports.

As this edition of NHE went to press, NHS England launched its ‘Next steps towards primary care co-commissioning’ report giving local clinical commissioning groups (CCGs) the opportunity to choose the model they would “wish to assume” and clarify the “steps towards implementation arrangements”.

The document suggests there are three primary care co-commissioning models CCGs could take forward including: greater involvement in primary care decision-making; joint commissioning arrangements; and delegated commissioning arrangements.

Presented by Ian Dodge, national director of commissioning strategy at NHS England, the paper stated that co-commissioning is recognition that CCGs are harnessing clinical insight and energy to drive changes in their local health systems.

“But these are hindered from taking an holistic and integrated approach to improving healthcare for their local populations, due to their lack of say over the commissioning of both primary care and some specialised services,” he wrote.

As a ‘next step’ the document says that NHS England will “continue to work on arrangements for involving CCGs in the commissioning of specialised services”.

When talking to NHE about commissioning specialised services, Dr Simon Bowers, GP and vice clinical chair of Liverpool CCG, said two words describe the current situation: complicated and vacuum.

“CCGs are very clear on what they need to do for the services they commission. When pathways get difficult to commission or start to run into trouble, it tends to be in the transition between generalist CCG-commissioned services and specialist NHS England-commissioned services,” he said.

“In Liverpool we’ve got more specialist trusts than anywhere outside London, so it is a particularly acute problem for us, commissioning services for both children and adults.”

He added that when Liverpool CCG came into statutory form the organisation stated that the city of Liverpool was its intended ‘unit of planning’, which meant that if someone was a resident of the city the CCG would be the lead planner and lead commissioner for services.

“So we would expect our colleagues in NHS England to work with and through us so all our pathways were consistent and seamless. That sounds great, but in practice there is a slight ‘vacuum’ where one would hope specialist commissioners would be. And it has been very difficult to get everybody in the right room at the right time,” he said.

“Liverpool CCG welcomes the conversation about moving some specialist services back to CCGs. It isn’t about building empires; it’s about giving commissioners who have the relationships and the intelligence out in their area the tools to do the job.”

Prescribed specialised services

Earlier this year the ‘Commissioning Intentions 2015-16 for Prescribed Specialised Services’ document revealed that from April 2015 CCGs, rather than NHS England, should have commissioning responsibilities for: specialised wheelchair services and outpatient neurology referrals made by GPs to adult neurosciences and neurology centres. Dr Bowers said: “Specialist wheelchair services should be commissioned at a local level. As far as I’m concerned it is a neighbourhood service and would form part of a package of care for an individual who should be in the centre of a team of local professionals working around them. Anything else seems ludicrous.”

The Walton Centre NHS Foundation Trust in Fazakerley, Liverpool, is one of the country’s leading and largest providers of neuroscience services. In the trust’s recent annual report it was noted that reconfiguration of specialised services may affect the range or requirements for provision of neuroscience services in a way that impacts the sustainability of the trust’s existing service model.

It added that there remains some “uncertainty” regarding the future commissioning of some elements of neuroscience services, which could see the CCG taking the lead commissioning role from 2015-16 for a limited number of services and treatments.

But Dr Bowers said: “The issue is a real hot potato in Liverpool as we have got a world-class super regional centre actually within the postcode of Liverpool that we do not have a contract with at the moment. It is completely illogical.”

He added that where CCGs have hit the ground running, and have earned their spurs in system leadership and transformational change, then those organisations should be the “conductor of the whole orchestra” – with their clinical leadership being vital.

Primary care co-commissioning

During our interview with Dr Bowers, following the recent ADHD Foundation conference, he said: “Our organisation has made it clear that you can play chess with hospitals all you want, but if you don’t get primary and community care and prevention and self-care right then the system is unsustainable.

“Being able to invest in the early part of the pathways is vital. That’s really difficult, though, if your commissioning responsibilities are limited.”

Under current legislation, Liverpool CCG has developed a separate contractual arrangement with its general practices that has seen an improvement in access, a decrease in unplanned care usage and has seen controlled levels of GP referrals with clinicians referring along evidence-based pathways.

But there have been concerns raised nationally about conflicts of interest within CCGs. NHS England has also stated that while guidance on this is already in place it is “to be strengthened in recognition that co-commissioning is likely to increase the range and frequency of real and perceived conflicts of interest”.

A national framework for conflicts of interest in primary care co-commissioning is to be published as statutory guidance in December 2014.

Dr Bowers said: “Anything that can assure the public and will assure the centre that CCGs aren’t playing a game where they feather their own nest, and the nest of those GP members of the governing bodies, is an absolutely good thing.

“At Liverpool we set up a separate panel of our non-executives, our non-GP clinicians, and some of our managers, where any decision goes to when the governing body might make a decision about a direction of change. If that involves an investment in general practice, we have an internal, but non-GP panel of managers.”

Delivering for local health economies

NHE was told that there is no secret in the clinical evidence that the best healthcare systems across the world are those that invest heavily in the front-end of pathways.

“You cannot get around the NHS conundrum without investing in primary and community care. We have just got to deal with that conflict of interest,” said Dr Bowers. “There will always be perceived conflict of interest and there will always be challenges from groups in the public, but if you’re transparent and honest about it I don’t believe it is a big jump from where we are now.”

Asked about the relationship between CCGs and Health and Wellbeing Boards (HWBs), he noted that historically the two come from different cultures that have been a world apart.

“But, actually, the challenges facing local government, particularly in the core cities and northern cities, are identical if not more acute than the challenges facing the NHS. Too many punters; not enough cash,” he said.

Recently shadow health secretary Andy Burnham suggested that if Labour won the next election CCGs could be morphed into the operational arms of HWBs – moving ultimate responsibility for NHS commissioning to local government.

But Dr Bowers noted that any further changes, especially ones that decrease the role of clinicians in commissioning of health services, would be a massive retrograde step 

“There has been a lot of expertise gained since CCGs came about and I think there is a risk to health economies of losing that expertise if you take away the accountability and statutory nature of the bodies that have been created,” he said.

“This would be a massive opportunity lost because CCGs are starting to cut through a lot of the bureaucracy with a clear clinical vision delivering a really good consensus leadership across the health economy.”

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