Clinical commissioning groups are key to transforming the NHS

In Corby, the CCG has introduced a new urgent care facility, and local people no longer have to travel eight miles for an x-ray. Photograph: Hans Neleman/Getty

For the past year clinical commissioning groups (CCGs) have been working hard to make a difference in a system that isn’t set up to support them. But in spite of increasingly unstable finances and an NHS that is still embedding and adapting to new ways of working, CCGs are making responsible, clinically-led decisions in partnership with GPs, patients and providers which are making a difference to the care being delivered to their communities. Our Taking the Lead publication highlights 16 CCGs across the country who are unleashing the power of clinical leaders, working with local government, the voluntary sector and other key partners.

The 16 examples show what results for patients the innovation, enthusiasm, energy and clinical leadership of CCGs can have – for example, in Corby, senior GPs now work part of their week in a new urgent care facility, and local people no longer have to travel eight miles to A&E for an x-ray. Or take Oldham, where the CCG is working with the local council and a housing association to lift people out of fuel poverty so that 1,000 households stay warm in the winter. In Leicester, health coaches are helping people with chronic lung disease to look after themselves, and in east London people recovering from mental ill-health can now be seen out of hospital in their GP surgery.

These are just a small sample of the range of integrated and innovative work that CCGs are leading all over the country. I’m not pretending that creating a high-quality and sustainable NHS is going to be easy, but the ambition and appetite from CCGs to make services the best they can be for patients is real.

Our members regularly tell us the good, the bad and the ugly of what is happening at the local level, so on 1 May we launched our CCG manifesto, Making change happen. The manifesto, which was developed by NHSCC members, is a system-wide call to ensure CCGs are supported to realise their potential and create a transformational NHS. The NHS chief executive, Simon Stevens, welcomed it and committed to working with CCGs to make it a reality. We were pleased to hear his announcement of new powers for CCGs in primary care, which recognises the need for a more integrated approach across the whole system.

The manifesto, which highlights eight challenging and critical asks, stresses the importance of every part of the NHS working with each other, and respecting the value that CCGs bring. All too often people don’t see clinical commissioning as an equal player in the system, but if we are going to transform services locally for the benefit of patients, CCGs must be at the centre of decision making.

The eight asks are:

1. Free clinical commissioners to act in the best interest of patients.
2. Make local system leadership a priority.
3. Health and well-being boards as the focus of joined-up commissioning.
4. CCGs must not be a risk pool for the NHS.
5. Support to deliver large-scale transformation at pace.
6. Connecting national and local commissioning.
7. Better alignment of local commissioning to healthcare quality and the new inspection regime.
8. Competition in the NHS in the best interest of patients.

With the general election due in 2015, we will also pursue the aims of the manifesto. We need to make sure that whichever party or parties are leading the country after the election understand the value and impact that clinical commissioners are having and why it’s critical that we don’t go backwards or face another massive reorganisation of the NHS.

The whole system – providers, local authorities, regulators, thinktanks, as well as NHS England and the Department of Health – needs to recognise the system leadership role that CCGs play at the local level, and appreciate their clinical expertise and patient understanding.

Our manifesto for change has some of the answers to those difficult and critical questions, and with more than 75% of CCGs in membership we have a loud, strong and collective voice, but working with each other, and not against each other, is the only way we can ensure the NHS transformation continues in the best interests of patients and local populations.

Dr Steve Kell is co-chair of the NHSCC Leadership Group and chair of NHS Bassetlaw CCG

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Clinical commissioning groups are key to transforming the NHS

Are clinical commissioning groups coping with the adjustments in the NHS?

Are CCGs straining under the weight of their responsibilities? Photograph: Victor Fraile/Getty Photos

Are clinical commissioning groups coping with the adjustments in the NHS? The response is very mixed. CCGs are nevertheless fairly younger organisations. They have just completed their 1st year as commissioning bodies accountable for setting strategic priorities for their patch and commissioning care for secondary (acute and psychological overall health) and local community care, and for co-ordinating closely with public wellness and social care.

This is no small activity. There are several cultural, organisational, budgetary and policy boundaries that divide and disintegrate care for sufferers and for populations. It is genuinely also early to tell whether or not CCGs will have the capability to give the daring regional leadership to make the changes essential to integrate care seamlessly for their population. The purpose should be to manage the care landscape so that men and women can navigate the various sectors with no encountering barriers or boundaries.

I have been impressed with the practical preparing that GP-led CCGs have proven. Their programs are among the best I have witnessed in the NHS as they are grounded in the expertise GPs have of their regional patient population and are centered on commissioning for outcomes, not merely process and outputs. By this I indicate they are interested in delivering optimistic influence on the well being and wellbeing of their population.

Regrettably, to do so at a time of reducing fiscal resources indicates there will be losers. The NHS has failed to deal with decommissioning efficiently. As quickly as a planned closure is recognized, there is a political and public outcry and most are quashed. CCGs and NHS England should be better at empowering local clinical leaders to lead decommissioning efforts on the basis that security and good quality of the care presently being delivered can be vastly improved through realigning delivery.

I see numerous barriers to CCG effectiveness. CCGs in my view are also small to have the impact they look for on managing a well being population. There should be mergers among CCGs, but it’s also important at the identical time to keep the regional target and flavour.

Disconnected patient degree information will be the bane to effective integration. A quick and low-cost remedy to linking patient care information at the level of services is essential. NHS England has been focusing on bringing all patient data collectively into a single large database. This has failed in the previous and will fail once more, as well as alienate the public.

CCG GP leadership is still fragile and I query whether it is sustainable. I have been very impressed by the zeal and commitment of neighborhood GP CCG leaders who are not compensated for the hrs of day and evening meetings they need to attend. Even more, if future governments reorganise the NHS again, I believe an whole generation of GP leaders will be alienated and misplaced.

Well being and wellbeing boards must be rethought. These are non-organisations with no spending budget and no personnel and but they have a sort of veto energy more than CCGs. Perhaps the reply is to require nearby politicians, as properly as public wellness leaders, to sit on CCG boards.

If there is severe curiosity in integration across well being and social care, and I believe there should be, then budgets should be aligned and ringfenced.

Thinking about how new CCGs are, local GP leaders by and massive have done a stellar job at identifying the most essential strategies to increase the health of their populations. The effectiveness of commissioning can only be fairly assessed in excess of time. Significantly is nevertheless to be completed to clarify the commissioning landscape amongst CCGs and NHS England. Moving to substantive integration of wellness and social care will consider bold clinical and administrative leadership that collectively can face up to the politicians, as solutions will have to be decommissioned. That will threaten the quite existence of some acute care trusts.

David Goldberg is global associate for Excellent Governance Institute

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Are clinical commissioning groups coping with the adjustments in the NHS?

Five top guidelines for commissioning assistance units

CSUs need to emphasis on efficient connection management and co-ordinating assets to improve overall health and healthcare, writes Leigh Griffin. Photograph: Alamy

This week marks the initial anniversary of the introduction of radically changed commissioning arrangements in the NHS.

These arrangements, which, through the creation of clinical commissioning groups (CCGs), placed clinicians in a position to lead choice-generating for neighborhood health solutions, also noticed the creation of commissioning help units (CSUs) to assistance CCGs and NHS England.

As managing director of the CSU serving Better Manchester, it truly is a helpful time to reflect on the 1st yr of operations. Here are my leading 5 reflections:

one Drop the ‘C’
We have a pivotal part in enabling the commissioners of a support to access expertise and skills at scale. As a provider of such companies, we can and need to also assistance NHS trusts, main care and the broader public sector, as we improve service co-ordination and good quality, whilst living within our implies.

As such, we are not basically ‘commissioning’ assistance units, but public sector support units.

two Integrate our efforts
In an era of resource constraint, it is critical that NHS organisations work together. We need to concentrate on effective partnership management, co-style and co-delivery to co-ordinate our use of sources and our collective commitment to enhance overall health and healthcare. Immature organisations revert to dysfunctional master-servant relationships, which we need to resist.

3 Our customer’s consumer is our customer
In searching for to strengthen our support to our clientele, primarily based on sturdy connection and account management, we must make our function clear. This is to allow our customers to enhance the wellness and healthcare of the communities they serve.

While we need to have to show worth to our having to pay clientele, it is crucial that both our employees and customers are ready to see how we are jointly improving well being and healthcare across Better Manchester.

four Flexibility and adaptability
It is evident that our clientele – CCGs, NHS England and neighborhood authorities – are seeking for consultancy and undertaking management or delivery-kind assistance to tackle both foreseen and unforeseen short-term issues.

This demands CSUs to be in a position to flex and adapt to these needs, as properly as operating closely with our consumers to foresee and speedily respond.

We aim to strengthen our capabilities and techniques of working to be a lot more responsive, constructing a powerful public sector consultancy skill base and, hopefully, minimizing the public sector’s demand for commercial sector support.

5 Efficiency
We must and will try to be much more productive to demonstrate greatest value to our consumers. Recognising the two the considerable monetary challenges dealing with the public sector and the steady emergence of a market place for commissioning help, we have to be reasonable and aggressive if we are to grow sustainable assistance to the public sector.

Locally, our programs to merge with Cheshire and Merseyside CSU reflect this need, as nicely as the opportunity to strengthen our service and ability base, and entice potential partners.

In summary, it truly is been a tough but productive initial 12 months. CSUs have discovered to be companies, recognising the imperatives of value and relationships. We now need to embed ourselves as providers of decision in a potential market for assistance solutions, demonstrating the actual skills, skills and expertise that the NHS can offer.

Leigh Griffin is managing director of Better Manchester CSU

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Five top guidelines for commissioning assistance units

Clinical commissioning groups the one-year health check-up

GPs are best able to lead on transforming the way healthcare is delivered, says Rick Stern. Photograph: PHOVOIR / Alamy/Alamy

In April 2013, CCGs were introduced to replace primary care trusts as the commissioners of most services funded by the NHS – and they now control about two thirds of the NHS budget. The key change is that clinicians play a greater role in deciding how funds are spent on commissioning services and all general practices in England are legally obliged to be a member of a CCG.

Not all GPs are involved with their local CCGs and therefore the extent to which GPs are actually engaged in making decisions about the management of the NHS varies. Kate Adams, a GP in Hackney, thinks overall engagement between GPs and CCGs is growing under the new arrangements. “GPs are working more closely together between practices and there is closer working between doctors and managers, which is a good thing,” she says. GPs have an important role to play in giving “clinical input to redesigning care pathways”, she adds.

According to a report by the King’s Fund and the Nuffield Trust, GPs who have got involved with CCGs have seen a definite impact – 66% of GPs who led CCGs felt that their CCG was “owned” by its members, compared with 35% of those without a formal role in the CCG.

Nicholas Hicks is chief executive of Cobic, a consultancy advising commissioners and providers on outcome-based healthcare services, which aims to secure “both value for money and better outcomes for patients”. He thinks that GPs will be instrumental in changing the way services are commissioned: “GPs are far more involved with commissioning than before and they bring fresh perspective, not least because they are less inclined to accept central directions that they do not believe make sense.” He adds that: “A fresh eye has meant that CCGs are far more open to adopting innovative approaches to commissioning than were the majority of their predecessor PCTs.”

Rick Stern, chief executive of the NHS Alliance, thinks the strength of the CCGs is their clinical focus and “different style and approach in leadership”. PCTs, he says, were felt to be “too distant and bureaucratic, and the real test for CCGs will be to show they are radical and different, and a break with the past.”

CCGs have two main roles – commissioning services and supporting improvement in general practice.

There is the opportunity here, Adams says, “to address the bigger issue of society, health and wellbeing – GPs understand how important this is and how to make an impact on people’s lives.”

Hicks agrees: “A growing number of CCGs want to commission in a different way – they are taking steps towards letting contracts that pay providers on the quality of the outcomes they achieve for people that use the services rather than on the volume of activity.” 

Traditionally, PCTs and CCGs place one-year contracts with providers such as hospitals in which the value of the contract is determined by the number of patients a hospital treats. Under the outcome-based model, Hicks explains, the provider (which may be a new alliance of hospital, community and social service providers) is given a “longer-term contract, a base sum of money for the care of a group of people (such as older people, people with drug and alcohol problems), and money for improving the outcomes for the people using the services.”

How services are commissioned is integral to managing change and we need a different style of commissioning, says Rick Stern. “CCGs must work with their patients and the wider community and work through difficult decisions – there will be massive problems with budgets in years to come and we need to look at transforming the way healthcare is delivered – this is a big and complex debate.” And it’s a conversation that the GPs are best able to lead, he says. “Are people willing, for instance, to let go of the sacred position of their local district hospital and have more services offered in the community and in specialised centres?”

Trying to improve and measure outcomes for people who use NHS services will be an area that every CCG will be working on but it will take time. As Adams says: “The future is about transforming services – giving benefits to patients and freeing up money for things that really matter – preventative and community health and wellbeing.”

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Clinical commissioning groups the one-year health check-up

A yr on, problems remain in the NHS clinical commissioning group system | Zara Aziz

‘GPs shouldn’t have to justify every single referral they make to hospital to their clinical commissioning group’ Photograph: Adrian Sherratt

Clinical commissioning groups (CCGs) came into being as statutory bodies in April 2013, as an intrinsic element of the government’s well being adjustments. Prior to this, they had existed in their “shadow” varieties when main care trusts (PCTs) have been slowly devolving.

The concept behind CCGs was to have frontline clinicians, this kind of as GPs, at the helm when it came to commissioning neighborhood and hospital care in England, and managing all around two-thirds of the NHS budgets. For instance, CCGs are accountable for commissioning outpatient, inpatient or urgent care received by individuals in their local hospitals. They commission district nursing and wellness going to services for their regional population. Nonetheless, NHS England nevertheless commissions GPs, and despite the fact that CCGs have been tasked with strengthening basic practice as a total, they do not hold GP contracts.

In my expertise in inner-city Bristol, since the start off of CCGs GPs have had far more clinical involvement. GPs, hospital physicians, nurses and pharmacists are all being represented on most CCG boards. This guarantees that the wealth of clinical expertise is taken from the consulting area to the boardroom.

A great deal of perform has gone into engaging frontline GPs like myself who are not actively involved with CCG operate. For instance, in our locality groups, we are often asked to engage in or come up with new initiatives to aid our nearby population groups. There have been some superb initiatives that have supplied GPs peer support and enhanced finding out in fields this kind of as paediatrics, prescribing and assistance for dementia sufferers. But there have also been challenges.

There is ultimately a finite sum of money accessible to CCGs and any services improvement has to be balanced towards cuts elsewhere. Referral management is an location that all CCGs appear at closely to create if any GP practices are “outliers”. So for instance, a GP practice that refers a good deal of patients to gynaecology clinics in hospital whilst its neighbouring practice has minimal referral prices may possibly come beneath scrutiny.

It could be that the practice has studying requirements or it might even be “overskilled” and consequently its GPs are far better at diagnosing troubles for distinct situations (that merit referral). Also numerous GPs work underneath demanding problems with spiralling workloads and can see between 30 to forty individuals a day, some of whom can be really ill. Obtaining to justify to the CCG every referral they make to hospital in the face of uncertainty, adds increasing pressure to that workload.

Occasionally our sufferers are unwell but could be managed in the local community, if we had ample district nurses or neighborhood matrons (which we will not). Usually it is the situation of the exact same individuals time and once more whom we struggle to maintain out of hospital when there are couple of beds and emergency departments are complete.

I know numerous CCGs are hunting at community-based alternatives to deal with these sufferers, this kind of as specialist geriatricians to advise us or “intermediate” beds (the place individuals can have some clinical care out of hospital). Ultimately, all these selections will be dependent on finances.

In contrast to PCTs, which have been created up of managers, GP-led CCGs comprehend GPs. Nevertheless, they may possibly not have the power or assets to change the huge picture. We are twelve months down the line and though there are constructive signs, we are still on unknown territory. CCGs do have hard challenges as they try out to apply their prolonged-phrase strategic programs, in the encounter of an ageing population and escalating prevalence of disease.

A yr on, problems remain in the NHS clinical commissioning group system | Zara Aziz

What can clinical commissioning groups find out from Oxfordshire?

‘Disrupting the health workforce in securing alter … is essential. New patterns of care will produce winners and losers,’ says Richard Vize. Photograph: Tom Jenkins

The unravelling of the plans by Oxfordshire clinical commissioning group to introduce outcomes-primarily based service contracts shows that even though commissioners have the money, companies are still running the program. What will it consider to break their energy?

Oxford well being basis believe in and Oxford University hospitals trust’s forceful objections to ideas for outcomes-based mostly commissioning of adult mental overall health, maternity and older people’s providers integrated the truth that the modifications would introduce new economic and clinical risks and impact the local wellness workforce. But they supported the general aims, of program.

Tell any discussion on public service reform that the public sector demands a new mindset to threat, and you can be sure that your comment will be greeted with vigorous nods. But commissioners and companies require to flip those sentiments into action. If introducing new dangers is going to be an acceptable cause for torpedoing reform proposals, then we will remain lumbered with the old hazards of working out of money whilst fitting our patients into solutions as an alternative of creating solutions round patients.

Disrupting the wellness workforce in securing adjust isn’t just a risk – it is vital. New patterns of care will generate winners and losers among personnel.

A gateway overview of Oxfordshire’s proposals by the Division of Wellness in light of the providers’ objections has far more than a whiff of political expediency. Drinking deep from the well of civil services clichés, it concludes that the CCG ought to see 2014-15 as “a transition year” with a “want to review the scale and variety of providers”. All this should be completed “having carefully imagined by way of all the implications”. And of course it calls for piloting.

Tellingly, the evaluation recommends involving the current suppliers in developing the new providers. While this might nicely be the right strategy on numerous events, it must surely be up to commissioners to decide whether or not it is in the greatest interests of sufferers. If, for example, a CCG believes an incumbent does not have the vision or expertise to build a new kind of services, certainly it must have the discretion to pursue a diverse route.

So the DH talks hard about enhancing the patient expertise, focusing on outcomes and employing competitors to carry about adjust, but when it comes to politically contentious selections – particularly ones affecting the prime minister’s constituency – it runs away.

The unravelling of the Oxfordshire strategies is very likely to be seen as a victory for inertia. It gives the message to trusts that if they resist difficult the DH and commissioners are probably to back down. It also reinforces the belief that in spite of the wellness reforms rebuilding the total NHS close to a commissioning program, the power of companies is undiminished. A mere act of parliament is no match for them.

CCGs could very easily consider away the lesson that ambitious changes this kind of as demanding incumbent providers and commissioning for outcomes will fail, and that they should opt alternatively for incremental adjust.

But if that takes place, clinical commissioners will have demonstrated that they are incapable of reforming the health service. Rather they ought to understand from Oxfordshire’s expertise about how to put together the ground for change.

It is clear from divisions in Oxfordshire CCG’s own ranks that it could have made a much better job of creating a coalition of support for its radical programs. Contracting is only a strong tool for large-scale change if it is accompanied by convincing clinical evidence and political support.

Many providers and CCGs are beginning to create robust and trusting relationships, on which they are developing a shared vision of the require to alter. But the place the partnership is much less constructive, CCGs simply do not have the clout to batter by means of modify in the encounter of concerted opposition. If pushing through adjust involves having a scrap with the incumbent provider it will need political guile, and tons of it. Commissioners cannot let providers to be witnessed as possessing the exclusive right to represent patients’ interests.

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What can clinical commissioning groups find out from Oxfordshire?