After more than 20 years of repeated reorganisations (culminating in one so big you can see it from outer space), policy-makers have finally navigated the purchaser–provider divide to focus their attention on the structure of health care providers. When the NHS five year forward view (Forward View) was published in 2014 (with its focus on developing new, locally designed integrated models for providing health and care) the broad thrust of English health policy shifted from commissioners and competition to providers and collaboration.
Although any pause in the cycle of top-down reorganisation is welcome, there is now a clear (and perhaps conscious?) gap in the policy landscape. How will clinical commissioning groups (CCGs) be affected as new integrated provider models such as accountable care organisations (ACOs) emerge and sustainability and transformation partnerships (STPs) and accountable care systems (ACSs) (that involve both commissioners and providers) are layered on top of an already complex NHS landscape?
Those running the NHS have said that this new world fundamentally changes the incentive structures in the NHS. According to the Secretary of State, Jeremy Hunt, in his recent fractious correspondence with Stephen Hawking in The Guardian:
…in many ways these models weaken the ‘internal market’, or purchaser–provider split, to allow integrated and joined-up care. We want to encourage this because it will improve the quality of care, meaning less resources are used up in complex contract negotiations.
Simon Stevens, Chief Executive of NHS England, went further in his evidence to the Public Accounts Committee in February, saying the purchaser–provider split would ‘effectively end’.
Despite this apparently seismic shift in policy, little detail has emerged about what this means for commissioners. Policy documents have either not materialised or include just a few sentences on what the future might look like. In the Forward View delivery plan, published earlier this year, NHS England talked about CCGs aligning themselves with STP footprints, but said little more. The future of commissioning organisations has been left for local areas to decide. This brings both opportunities and challenges for the system.
Three key themes are likely to characterise the development of commissioning over the next few years.
Collaboration. CCGs are already working more closely with their neighbours – either by sharing staff, setting up joint committees/governance structures or merging. This trend will continue as CCGs align more closely with their STP footprint. As will the trend for closer collaboration between CCGs and local authorities to integrate health and care commissioning. Add to that more collaboration with providers to jointly plan local services through STPs and ACSs and it’s clear that skills in developing and managing relationships and leading change across systems will be more important than ever over the next few years.
Delegation. This includes delegation within the commissioning system – since 2013 NHS England has delegated new responsibilities for general practice and some specialised services to CCGs, with more planned – and delegation out of the commissioning system – as new models of care develop, some CCGs are likely to take on a more strategic commissioning role, delegating some of their functions to groups of providers or ACOs, with whom they will agree a large capitated contract that leaves the provider responsible for much of the ‘operational commissioning’ required to deliver it. These changes affect the skill sets needed within CCGs and may require some staff to move between organisations.
Variation. As local areas forge their own paths, commissioning is likely to look increasingly different in different parts of the country – with some places running full steam ahead towards a more strategic model, while others maintain structures and roles similar to those they have today. Even the most go-ahead CCGs will need to play different roles depending on which organisation they are commissioning from. They may be a ‘strategic commissioner’ when interacting with a large local ACO and an ‘operational commissioner’ when commissioning other services. This creates challenges for CCGs (simultaneously fulfilling multiple roles) and regulators (who will need to define what good looks like in a varied system).
Beyond these developments, the big system changes (like the blurring of purchaser–provider split, and the development of ACOs) present some quite profound questions about the role of commissioners. Do we still need commissioning organisations in this more integrated system? What is possible within our current legal framework? What does being more strategic mean in practice? How can the centre hold integrated local systems to account for their performance?
With such fundamental issues in play, leaving the vision for commissioning to local areas may not be sustainable over the long term. However, NHS England faces a challenging balancing act. On the one hand, encouraging local experimentation and evolution will generate novel solutions, garner local ownership and allow each area to build on its strengths. On the other, without a certain amount of central direction some areas will fall further behind (particularly those where collaboration and transformation have been difficult in the past) and effort will be duplicated as many local areas grapple with the same fundamental questions.
As CCGs and STPs look to take major strategic decisions about the future shape of commissioning and provision locally, there is, as yet, no one clear answer to what a high-performing planning function should look like in the context of new models of care.
On 11 October The King’s Fund and NHS Clinical Commissioners are holding a conference on the future shape of commissioning to explore these issues further.
To inform debate, NHS Clinical Commissioners will be publishing an infographic and research report in late September to outline its membership’s views on the complexity of moving towards strategic commissioning. In November, It will be publishing a paper on what the strategic commissioning function looks like – examining international evidence and views from the commissioning sector.
Our new explainer answers the questions what is commissioning and how is it changing?