Clinical commissioning groups have scored some early successes but need a change of direction if they are to be truly effective, says Richard Lewis
Clinical commissioning groups, formally established in 2013, must be considered still relatively new.
Like other incarnations of primary care led commissioning before them – such as GP fundholding, primary care trusts and practice based commissioning – CCGs have attempted to harness the clinical knowledge of GPs and other primary care professionals to strengthen the commissioning function.
CCGs have brought forth a large cadre of clinical leaders and, despite their youth, it could be argued that they have had some successes.
“A majority of all GPs surveyed felt that the CCG had changed their adherence to referral pathways and their prescribing”
Surveys carried out jointly by the Nuffield Trust and the King’s Fund suggest that GP engagement with CCGs remains higher than that achieved under practice-based commissioning.
Perhaps unsurprisingly, a large majority of GPs with a formal CCG role felt engaged with the work of that CCG. Better still, a majority of all GPs surveyed felt that the CCG had changed their adherence to referral pathways and their prescribing.
More worrying though, the proportion of GPs that felt they could influence their CCG fell to a third this year compared with nearly a half in 2013.
Over this same period the proportion of GPs feeling highly engaged with their CCG fell from 19 per cent to only 11 per cent.
So, something of a mixed scorecard so far. But if CCGs are at least beginning to make progress, should they not just be allowed to continue; building on successes and addressing their weaknesses?
There are at least two reasons why this may not be a sustainable or indeed desirable option.
The first is pragmatic. With the advent of GP federations and a multitude of primary care enterprises designed to offer extended primary care and new models of integrated care (in particular, multi-specialty community providers), there may simply not be enough leadership talent to service both new provider organisations as well as the governing bodies, committees and other clinical groups of CCGs.
Given the emphasis placed on new care models within the Five Year Forward View, they cannot afford to be denied the best GP leaders.
If the first reason is related to competition for talent, the second relates to competition for role.
Guarding against monopolies
CCGs were designed to shift the focus of commissioning away from contract management and towards clinical service redesign. And yet the job of redesigning services is at the heart of new care models such as the MCPs and primary and acute care systems.
In a very real sense the role of agreeing service specifications is leaping from the commissioner side of the divide to that of the provider.
Indeed, many commissioners are exploring the benefits of agreeing capitated budgets with providers and passing to them the responsibility of making ends meet through the development of new care options.
”Collaboration is good, but it can also lack bite and external challenge”
So does this mean that the commissioning function is no longer needed? Far from it.
While clinicians delivering the new care models may well prove adept at designing and implementing effective services, who will ensure that they are always fully directed towards the needs of patients and local populations? How can we guard against professional monopolies?
One might argue that the determined drive towards care integration has sometimes been at the expense of competition – new care models are often based on a collaborating array of local providers.
Collaboration is good, but it can also lack bite and external challenge.
In these circumstances, commissioners remain vital in setting priorities, holding providers to account and ensuring that the voice and interests of the patient is heard. And it was to deliver these functions that commissioners were created in the first place.
But if the commissioner function is still required, this does not imply that the commissioners themselves must remain precisely the same as they are today.
The roles described above do not all have to be carried out by primary care professionals – indeed they may be better performed by others, in particular those not elected by the provider membership.
One might also argue that a larger geographical footprint, with fewer CCGs, would support a strengthening of management and a redressing of the power imbalance with increasingly large and powerful foundation trust sector (a point made by the recent HSJ Leadership Inquiry).
The implications of this, of course, are that the ceaseless search for the right commissioning roles and structures must continue. And with change fatigue high, evolution rather than revolution might be the order of the day.
Richard Lewis is partner and health leader, EY