Why did we do this work?
In recent years national policy has been emphasising the importance of collaboration within local health and care systems. Since the NHS five year forward view in 2014, several initiatives, including the new care models programme and integrated care systems (ICSs), have promoted collaborative approaches in which providers from different parts of the NHS or providers and commissioners work together to plan and develop services. The NHS long term plan has indicated that ICSs will cover England by 2021.
These developments have major implications for how commissioning operates in practice. Yet recent national policy documents – the NHS five year forward view and the NHS long term plan – have not provided a national blueprint for commissioning structures. Local systems have instead had scope to evolve commissioning arrangements to suit their circumstances. Consequently, a range of approaches is developing, and different parts England are at different stages in these developments.
We wanted to understand how commissioning arrangements are developing in practice. Our goals were to:
- understand the approach being taken by some clinical commissioning groups (CCGs) and local systems that are re-thinking the role of commissioning
- draw out learning for other areas as they work to change their approach
- explore the national policy implications of this new way of working and what national bodies can do to support its development.
Our research approach
We identified two CCGs and one group of CCGs that were implementing new ways of planning services. These were:
- South Tyneside – a CCG in north-east England that is adopting a service planning model based on the approach of the Canterbury health system in New Zealand
- Tameside and Glossop – a CCG in Greater Manchester which has come together with Tameside Council to create a single planning organisation for most local public services
- Bradford district and Craven – three CCGs in West Yorkshire that will be merging in April 2020 and are establishing partnership arrangements to plan services.
We interviewed a range of stakeholders – around 40 in total – working in each local system. Subsequently, we convened a roundtable with commissioners, providers and representatives from sustainability and transformation partnerships and ICSs in other parts of England as well as national organisations and academics to test our findings and explore the implications for national policy and practice.
Common across our case study sites was a new ethos of commissioning. Traditional notions of commissioning are no longer guiding their way of working. Instead, these areas are focusing on new ideas around how commissioners can add value to local systems: bringing stakeholders together to make decisions; fostering close operational partnership between commissioners and providers; simplifying financial arrangements; and offering improvement support to providers.
Each case study site has used different combinations of these ideas and uses slightly different language to describe its role, for example, being a ‘facilitator’, ‘enabler’ or ‘connector’. But collectively their ideas add up to a paradigm shift in thinking about their role and how to drive improvement in health and care services. The table, below, summarises some of the key changes we saw.
|Health care focus||Population health focus|
|Organisational focus||System focus|
|Contract enforcer||System enabler|
|Transactions||Relationships and behaviours|
|Decision-maker||Convener for collective decisions|
|High bureaucracy, low trust||Low bureaucracy, high trust|
|Monitoring organisational performance||Monitoring system-wide performance and providing improvement support|
|Following national guidance||Developing local solutions|
These different ways of thinking are driving tangible changes in how these commissioners deliver their functions throughout the commissioning cycle – strategic planning, procurement, and monitoring and evaluation (see Figure).
- Strategic planning is increasingly a collective activity in which system partners come together to understand available resources, explore local population needs, agree priorities and make resource allocation decisions looking across health services (and in some cases, across health, social care and wider public services).
- Procurement processes are being simplified wherever possible. Areas are using competitive procurement as a tool of last resort. At the same time, financial arrangements between commissioners and acute providers are being simplified – through block or aligned incentive contracts – to tackle incentives that create tension within the system.
- Performance monitoring increasingly focuses on the performance of the local system rather than individual organisations. For example, some places are implementing system-wide financial reporting and focusing on population health outcomes as the key indicator of system performance. Monitoring and evaluation are the least developed parts of these new models of commissioning.
Case study sites are implementing these changes in different ways. Each place has different priorities based on local history and organisational context. Bradford district and Craven is largely focusing on collaboration among NHS organisations while South Tyneside and Tameside and Glossop is focusing on collaboration between the NHS and local government.
Strong relationships among key stakeholders are central to these new ways of working. Building mutual understanding between commissioner and provider leaders in local system takes time – but is essential. Developing shared views and understanding among senior leaders goes alongside a wider process of change for operational staff that focuses on supporting them to work more effectively with colleagues in other local organisations.
All our case study sites are developing or have developed structures to support collaborative service planning. But formal changes to organisational structures and governance arrangements are only one part of their change processes. Informal mechanisms for kickstarting change and role-modelling collaborative values are essential as well. In South Tyneside, for example, an alliance leadership team, which brings senior leaders together to discuss operational challenges, is central to how local organisations work together without being a formal decision-making meeting.
Changes to the commissioning process have led to changes in some staff roles. CCG finance and performance teams are increasingly taking a relational – rather than compliance – approach with providers. Finance and performance functions are focusing on improvement support rather than performance monitoring. In Bradford district and Craven, these developments are being supported by changes to recruitment decisions to meet system needs.
Learning for other commissioners and local systems
Our three case study sites were not representative of the wider health and care system in England: they are relatively self-contained health economies and Tameside and Glossop and South Tyneside are smaller-than-average CCGs. Other parts of England will need to adapt any learning from this study to their local circumstances. Key learning points include the following.
- Agreeing a set of shared values can be a useful resource when challenges arise. Tensions between stakeholders within collaborative planning arrangements are inevitable, but our case study sites found a defined set of values helpful as a way of anchoring conversations at times of difficulty.
- New collaborative commissioning approaches mean commissioning staff may need to work differently. After nearly 30 years of a quasi-market framework, collaborative commissioning requires different behaviours and involves navigating uncertainty. For some staff this can be challenging; all the case study commissioners were investing in organisational development.
- Clinical involvement in commissioning has changed and will continue to change. As collaborative commissioning arrangements increasingly look to influence population health, a broader range of expertise – for example, from social care and allied health professionals – will be needed in service planning discussions.
Moving to a more collaborative model brings some risks, for example, regarding how to manage conflicts of interest and ensure transparency without introducing unnecessary friction into commissioning processes. While these risks are not unique to collaborative models, they demand careful management. Our case study sites were managing these issues as they arose. However, leaders in the sites felt the costs of managing these risks were far outweighed by the opportunities presented by collaborative planning. Interviewees spoke about how their approaches were enabling different conversations within their local systems which, in turn, were supporting positive change in patient-facing services. Practical day-to-day gains were also clear to staff. All our case study sites intend to continue embedding and refining their ways of working.
Implications for policy and practice
Our case study sites were implementing changes within existing legislative arrangements, but in some ways current regulations obstruct, rather than support, relational ways of working. It takes constant effort to model a collaborative ethos in the face of a legal framework that encourages more adversarial methods.
National policy needs to be adapted and national bodies need to work differently and work with local systems to maximise the opportunities associated with collaborative planning.
- According to current national plans ICSs will be co-terminous with CCGs. Yet merging CCGs by default risks undermining local collaborative planning structures. NHS England and NHS Improvement should work with local leaders to take decisions about the size and structure of CCGs on a case-by-case basis.
- NHS England and NHS Improvement’s regional teams have an important role in supporting the development and spread of collaborative commissioning models. As new approaches develop, consistency in regional oversight will be critical to ensure risks are managed effectively and innovation is not stifled.
- National bodies’ existing model of assurance is mainly focused on organisations rather than systems, which risks hampering the progress of collaboration. Changes to the assurance regime will need to strike a better balance between organisational and system-level scrutiny as well as national versus local line of sight.
- National bodies should support leadership and organisational development in CCGs. Embracing collaborative models of commissioning entails sustained culture change for staff. National NHS bodies and ICSs have a role to play in supporting this change process.
Would like to better understand the level of discretion available to CCGs given the FUNDING MODEL employed by the NHS to allocate finance to the CCGs and then by them to their Service Providers. I have gained the impression that there are so many foreclosed choices within the system that very little real discretion is available, and that within very narrow margins. Is it not therefore misleading to suggest that there is the scope for the reforms implied in the study?