Commissioning is dead. Long live commissioning.
By James Peskett, PA healthcare commissioning expert
PA Consulting Group and HSJ recently conducted a survey of 100 Clinical Commissioning Group (CCG) leaders, which shows CCGs are responding in a variety of ways to the more pessimistic financial outlook they face in the coming year.
They are moving away from traditional market mechanisms, such as choice and competition but are more focused on both tougher performance management of existing contracts and the introduction of novel contract mechanisms. They are showing a strong interest in accountable care systems but much less enthusiasm for accountable care organisations. We are also seeing a recognition that CCGs will need to do more joint commissioning, but that does not necessarily mean providers gaining more influence over system leadership.
We found polarised views about the financial health of CCGs for the year to come. Forty per cent of respondents overall remained confident (scoring seven out of ten or higher) their CCG would stay within budget in 2016/17, though this was down on previous surveys. However, over a third of CCG leaders had little confidence (scoring three out of ten or lower) they could do the same.
We asked CCG leaders (chairs and accountable officers) about the importance of different commissioning methods over the next 12–18 months. The results set out in figure one show a clear preference for redesigning existing services using current providers. This ranked above patient choice or tendering services as mechanisms for change. Many NHS providers will welcome this; however, those who represent patients and – ironically – private providers may be less convinced this is the best way to go.
Over half of respondents thought applying existing contractual levers would be fairly or very important and did not appear to see a contradiction between this and seeking to improve and maintain relationships with providers. This may be wishful thinking, as the widespread difficulties over the 2016/17 contracting round shows CCGs are struggling to do both successfully.
When asked about the role of commissioning in the Sustainability and Transformation Planning (STP) process, CCG leaders were clearly interested in the possibility of integrating services and sharing more functions with neighbouring CCGs and/or local authorities. (See figure two below.) However, they were less convinced that providers would take on greater responsibility for population health, or that individual providers would become more dominant in their local health care systems. And CCG leaders were quite clear they did not see themselves stepping back from setting strategy to allow STP convenors to take on this role. This suggests commissioners are striking a pragmatic compromise, being willing to work together with partners on areas of common interest, but wary of formally giving away power to those in new roles or organisations.
This provides a possible explanation as to why respondents showed a marked preference for forming accountable care systems (ACSs) and/or new alliance contracts, rather than accountable care organisations (ACOs). (See figure three below) ACSs – still a new term in commissioning – could potentially involve fewer formal structures and less transfer of responsibilities from commissioners to providers, than ACOs. The emphasis on alliance contracting, rather than the lead provider model, also helps to avoid any one provider becoming too dominant. Both ACSs and alliance contracts are a good fit with CCGs’ preferences for working with existing providers to redesign services through improved relationships.
These results are encouraging as they show CCG leaders are developing greater clarity about their own roles and how they wish to execute them. The wider NHS should welcome this new self-confidence after an extended period of change in responsibilities for commissioning.
Some CCGs have always commissioned collectively, through shared senior management teams and/or (con)federations. The Better Care Fund – and now devolution – are also driving CCGs and local authorities to pool commissioning budgets and functions. Equally, they are responding to NHS England’s transfer of its direct commissioning responsibility for primary care and specialist services to CCGs through co-commissioning.
Other changes are being seen in the Vanguards programme as it shifts commissioning accountability from CCGs to new provider configurations, such as primary and acute care system (PACS) and multispecialty community partnerships (MCP).
In addition, some CCGs are empowering patients to take over responsibility for purchasing their own health and social care through personal budgets.
Whether it is through ACOs or ACSs, all this underlines that CCGs are continuing to drive a trend towards less nationally homogenous, more locally determined health and social care systems.
However, the key to making any commissioning structure work is not so much in the organisations themselves as the connections between them. Despite their apparent reluctance to share power with providers, it is encouraging that CCG leaders do appear to understand seeking to improve relationships is critical to success. It will be interesting to look at the views of those on the other side of these relationships, the provider leaders, to see how they interpret their roles in the future. In particular, it will be important to assess the extent to which they are attracted by accountable care systems. The other critical question in the development of new commissioning structures is the response of patients. Will they be more willing to accept reductions in choice if they bring genuine improvements in their experience of care? This underlines that if CCGs are going to create new commissioning and system governance structures, they will need to be made to work effectively, by clearly defining the roles and responsibilities of all system partners in designing and delivering people's health.