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The future of clinical commissioning

Dr Graham Jackson, co-chair of NHS Clinical Commissioners (NHSCC) and chair of NHS Aylesbury Vale CCG, discusses the changing landscape facing commissioners. 

Since they were set up more than three years ago, CCGs have demonstrated a great ability to innovate and develop services according to a local population’s needs. They have also continually had to adapt and change the way they work. Going forward, this is something I expect to see more rather than less of. Simon Stevens’ recent remarks to the Public Accounts Committee and the anticipated content of the upcoming Five Year Forward View (FYFV) delivery plan only reinforce this view. 

Last year, NHSCC’s discussion paper, ‘The Future of Commissioning’, set out that that going forward we are unlikely to see a single model for clinical commissioning. It was equally clear that unless there is a change in law CCGs retain their statutory functions and responsibilities, albeit they can – and are – able to delegate through contracting some of the daily transactional elements of the job through new models of care. Where this is right for a local area, CCGs are welcoming this, as I explore further below. 

So, what are the key elements for clinical commissioning going forward?

Clinical leadership 

I strongly believe that clinical leadership embedded in the management structure of the NHS must be supported and maintained, whether that’s in CCGs or in the new care models emerging. Bringing in people like me – jobbing GPs, who aren’t enmeshed in NHS management – has been crucial to commissioning. We must preserve that local clinical voice and influence, or clinicians will simply go back to the day job. We need to find ways to encourage experienced leaders to stay in commissioning, while nurturing new talent and supporting the leaders of tomorrow – something that NHSCC is looking to do through its leadership work. Clinical leadership must be very much part of the future of commissioning or the NHS and patients will be poorer for it. 

New models of care 

New models of care create new opportunities. The FYFV recognises that traditional models of care need to change, which we are seeing as accountable care systems start to come into effect. Commissioners are embracing these, which in some cases will lead to a change in the way we work.  As I set out above, while CCGs legally cannot delegate their statutory functions, they can contract for some of the daily transactional elements to be delivered differently through these structures. This can provide an opportunity for CCGs to focus on the strategic side of their role. That’s not to say it’s simple – new care models need work, collaboration and to grapple with complex structural and resource issues. However, with their potential to bring about positive change, organisations may decide the benefits far outweigh the challenges. 

Focus on ‘the place’ 

We have increasingly moved towards more commissioning across ‘a place’ with new models of care and sustainability and transformation plans (STPs), and this is something that I see continuing. With this happening, we need to make sure there is an equilibrium between the focus on the needs of the local populations, and balance that against the necessity of working at scale when doing so would be prudent. There are commissioning and provision decisions that are sensible to make at scale and this is where STPs can play an important role. Our responsibility is to make sure localities are not isolated and CCGs remain well placed to defend the ‘sovereignty’ and needs of the local communities they serve. 

Increased health and social care integration 

Increased collaboration, between CCGs and across the system, is certainly something we expect to see even more of through STPs and other local innovations. STPs provide the potential to further break down organisational boundaries, and build on the health and care integration that is already taking place through developments such as pooled budgets and alliances. Commissioners, providers, local authorities and the voluntary sector all need to work together to look at whole-population health. 

Focus on the long term 

I hope to see these developments in the commissioning landscape allow clinical commissioners to focus more on long-term strategic priorities. CCGs are already carrying out a lot of work that focuses on prevention, as demonstrated in NHSCC’s ‘Delivering a Healthier Future’. The shift to the two-year tariff, allocations and contracting was a step in the right direction – even though contracting brought a challenging timescale. 

But the fact remains that often with longer-term programmes, significantly more time than one fiscal cycle is needed to reap rewards. This is something that clinicians know, and must be further recognised by all stakeholders in health and care – including politicians – if we are to have a long-term sustainable NHS. 

What is the future of clinical commissioning?

We are seeing changes in the health and care system and an evolution for CCGs. These changes are bringing challenges and opportunities for clinical commissioning and the NHS as a whole. The future will see a diverse range, rather than a single model of commissioning – but the clinical voice within commissioning must stay. Working with partners across the system, clinical commissioners have a crucial role in bringing about a transformed, sustainable NHS that delivers for patients. 

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