Clinical commissioning groups are fundamentally member organisations, and in similar organisations, it is the members who determine the configuration. Attempting to force these configurations will only lead to members feeling like they are not in charge.
This is the first challenge that clinical commissioning groups face and, if they are unable to address this issue, why should we expect them to succeed at the more challenging issues that commissioning will send their way? There is no simple answer, but the roots of the solution lie in collaboration.
The question concerning effective boundaries for commissioning has been clarified recently by David Nicholson's statement that mosaic structures – where one clinical commissioning group has a practice from another clinical commissioning group locality within it – would not be acceptable. Clearly pragmatism would apply and those on the borders considered in light of patient flows and the views of the clinical commissioners.
However another question – that of size – has prompted many to call for the protection of the smaller commissioning groups. And with the recent announcement of a running cost allowance of £25 per head in the clinical population, there is also an intense focus on affordability. With each statutory clinical commissioning group having fixed costs (such as governing body and audit fees) it implies that the smaller the group, the smaller the amount left from this allowance to use for all the other commissioning functions.
In addition to the argument that larger groups can achieve economies of scale, the history of commissioning, here and internationally, suggests that in order to manage financial risk, groups need to be large. There is also a strong case for bigger groups if they are to lead reconfiguration and drive significant change in the shape and pattern of services.
So would small groups really be able to deliver the change we seek? An observation – call it anecdotal, but it chimes with experience – is that smaller groups seem to develop a sense of ownership quickly, enabling change to occur at a local level. This seems harder to develop across larger groups, where the clinicians may be from different communities and are not necessarily like-minded. Does this higher level of engagement from smaller clinical commissioning groups translate into added value?
We have seen many examples of smaller groups coming together under the umbrella of a single clinical commissioning group; Cumbria, and Cambridge and Peterborough being two examples. These groups benefit from sharing the fixed costs, yet retaining locality autonomy. Most examples are groups that have been working for some time to develop local ownership and infrastructure, giving a great deal of thought to how risk will be managed across the group. In particular, they seem to have developed a high degree of internal trust.
Given the policy and economic pressures to form larger clinical commissioning groups, one solution may be for like-minded practices to form into provider federations at locality level. Over time, these practices could take limited financial risks through capitated payments from the clinical commissioning group to take greater responsibility for the financial consequences of their decisions and the quality of care they deliver to their patients.
The desire to come out with a number – the minimum size for a clinical commissioning group – is tempting, but it would be misleading, as the outputs of clinical commissioning groups depend on many factors. You can certainly envisage that smaller clinical commissioning groups who work successfully across boundaries may be more effective than larger groups that fail to collaborate.
So while size may be a factor, it is the ability to work across organisational and sector boundaries that will help clinical commissioning groups to achieve their goals. This will ensure the evolution of our NHS and the transformational change needed. After all, our patients rarely understand the strange and artificial boundaries that we place in front of them anyway.