Should specialised commissioning land on CCGs?

Source: NHE May/Jun 16

The NHS has grappled with the specialised commissioning debate since the introduction of the Health and Social Care Act. Here, the chair of Mid Essex CCG, Dr Caroline Dollery, lays out the pros and cons of putting these services back into local hands.

Specialised commissioning has always been a thorny issue for the NHS. At last year’s Commissioning Show, the director of the Specialised Healthcare Alliance told delegates that “a lot has gone badly” financially since the Health and Social Care Act 2012 threw that responsibility to a national level, leading to a ‘policy-paralysis’ that left many patients in limbo. 

This April, a National Audit Office (NAO) report determined that spending on specialised services posed a threat to the financial stability of the health service. The auditor concluded that NHS England had consistently failed to keep spending under control. In response, the leader of NHS Clinical Commissioners (NHSCC) said it “makes sense” for CCGs to be more involved in this process.

This year, the same issue will return to the spotlight during the Commissioning Show, where clinical directors and mental health leaders will, once again, debate whether specialist commissioning should be the responsibility of CCGs. 

Broken patient pathways 

Speaking to NHE ahead of the conference, Dr Caroline Dollery, one of the speakers at this debate and chair of Mid Essex CCG, made clear that there are pros and cons to putting these services in local hands – but argued the positives ultimately outweighed the negatives. 

Dollery, who is also clinical director for the Strategic Clinical Network (SCN) for the East of England for mental health, dementia, neurology and learning disability, explained: “I think it’s interesting to reflect on how this started, because when CCGs were set up, David Nicholson [former NHS England CEO] took the decision to put specialised commissioning into NHS England, and what happens then is you break up the clinical pathway. 

“That’s been much debated over the last few years between CCGs and NHS England. A really good example of that is in mental health, where, if you don’t have good connectivity along the pathway of your team – crisis care is a good example – you can’t put steps in for prevention and early intervention that stops people escalating into specialised commissioning. 

“And equally, you have lower influence when they’re in specialised services to get them out quickly.” 

With people commissioning different elements of the pathway separately, people can get siloed. “It makes much more sense for specialised commissioning to be part of the pathway rather than sitting somewhere separate,” Dollery added. 

“And you get to see that from patients’ families and carers, too – they get a bit frustrated with the perceived barriers between non-specialised and specialised services. There’s an opportunity there, without a doubt. Clinically, and from a service user perspective, it ought to be an improvement.” 

The skills challenge 

But while bringing services into CCG control has its merits from a patient flow perspective, it would not, at first, come without challenges. One of the risks is that commissioning groups will not have the right skills to actually carry out this responsibility, said the CCG chair. 

“It’s going to be really important to make sure that when the budget comes over to CCGs, which I think it should, that we are also able to access the right skills and resources that NHS England has at the moment,” she noted. “In other words, we ought to be able to transfer over some of the commissioners who have specialised commissioning skills to support us in the work.” 

While there is precedent for that – with various people in specialised commissioning welcoming this shift – the transfer could mean CCGs get less budget and resources than what NHS England has currently. “That’s a risk, and you just have to mitigate that risk,” Dollery argued. “And with a good bit of planning, you can do that.” 

In practice, this takeover could mean some NHS England staff become part of CCG teams while ensuring all commissioning bodies across the country work collaboratively to design a “good and sound” strategy. NHSCC would pay a big role in helping navigate this, as well as the SCNs, who could help support quality improvement and assist CCGs to ensure there is “consistent clinical governance” presiding over evidence and outcome-based approaches. 


Joined-up strategies 

The NAO report also made abundantly clear that there must be an “overarching strategy” for specialised services across the country, integrated tightly with the FYFV to ensure there are long-term plans in place. 

Dollery said: “The bonus of bringing the budget back [to CCGs] is that it allows us to properly design a good strategy. What is clear from the NAO report is that we need to have a joined-up strategy, and because CCGs are used to working in a very pressured financial environment, perhaps they are going to be quite good at that as well.” 

Another major driver will be the ongoing sustainability and transformation plans (STPs) currently being put together by footprints ahead of the 30 June submission deadline. In Dollery’s experience, these plans are already bringing CCGs together across bigger patches to look at population health more broadly. 

Nationally, while STP deadlines have been quite tight – hindering full engagement to a certain extent – and leader nomination processes have been carried out without much consultation, the chair argued bodies are already reaching out to CCGs. “It’s definitely an opportunity,” she added. 

Engaging and empowering patients 

Asked if the national grip on specialised commissioning is obstructive to her personal work at Mid Essex and hinders long-term planning, Dollery assured they have a good working relationship with NHS England and try to work tightly with them.

But because the financial governance is so separate, she said, it makes this very difficult. “It’s unfortunate we have this kind of separation between NHS England and CCGs, and it would be a positive if we could get better joint working across the pathway, because that’s what we need to think about,” she explained. 

“It’s about having a strong patient voice in all of this, which we would get more in CCGs, and perhaps losing some of the artificial barriers that exist at the moment between NHS England and CCGs.” 

In her CCG, which has been historically underfunded, Dollery said she has really good patient engagement, with staff always seeking to improve consultation so service users can better understand the challenges they face. 

Bringing back specialised commissioning would mean patients can finally be included in that debate. But, at an even broader scale, it would support the aspirations of CCGs moving towards more multidisciplinary approaches to delivering care, with the patient as a centrepiece. 

“You have that patient at the centre and you wrap around that patient primary care, social care, mental health, voluntary sector services – things like social prescribing and taking pressure off primary care so people can self-manage more,” Dollery said. “CCGs must be the system leaders in this because they have a real reach in their local communities: they actually understand their local communities in a way other areas don’t.”

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