As commissioning changes, Sarah Baker explains how Warrington CCG hopes to find its way through the early days of the new system to provide patients with a seamless service

Man with umbrella

CCGs have stepped out into a new and still developing landscape

What does the new commissioning landscape look like, post-April 1?

Several people have produced diagrams in an attempt to illustrate it; the Nuffield Trust’s slideshow is one such example. It describes the pre-reform structure − the Department of Health plus 162 organisations − in one neat slide, but five slides are needed to describe the world since April. Even these complicated diagrams do not reflect the sheer complexity of commissioning for the needs of individuals in the new world.

The number of hand-offs in commissioning responsibility along the patient pathway have increased significantly. To effectively commission services that appear seamless from the patient’s perspective requires extremely close working between numerous organisations and there are some critical interactions.

Areas of responsibility

At Warrington Clinical Commissioning Group, we are working very closely with NHS England (Cheshire, Warrington and Wirral). Warrington has historically lacked doctors and been an underinvested primary care sector. This has an impact on our ability to move care into the community.

‘We all know service reconfigurations cause public concern − everyone wants the best services, but everyone also wants them provided locally’

As a CCG we need to be actively involved in developing the strategy that determines the quantity and shape of GP provision in our area of responsibility. We need to lead the conversation about primary care development, quality and assurance, but the local area team has responsibility for the contractual elements of this. This team is responsible for responding to causes for concern about individuals on the GP register, and for appraisal and revalidation.

The information that responsible officers will require for the latter is the same as that we will require to ensure the quality of delivery of the primary care element of the patient pathway by our members. We must avoid duplication of effort in the production, analysis and access to this information while making sure it is fit for purpose for all parties.

We need to develop processes to ensure the CCG is informed about causes for concern relating to its members, while keeping appropriate confidentiality. Similarly, we need to share issues brought to our attention with the responsible officer.

The pattern and provision of primary care premises will constrain our ability to transform and provide services in the community. Routine investment decisions regarding general medical services premises lie with the local area team. If we wished to develop a mixed use building, we would have to also work with NHS Property Services and Community Health Partnerships.

Specialist commissioning

Of the 27 local area teams, 10 are also responsible for commissioning specialised services. However, they are responsible for commissioning all activity at providers with specialist services within their geographical patch, regardless of the individual’s residential postcode, not for specialist services for a geographical population.

This begins to produce even more complexity. As funding for specialist services is provider specific and non-geographical, how do we go about developing a local integrated pathway?  

It may be that a particular specialist intervention has a significant outcome for 20 or even 200 patients. However, if the cost of this could purchase less specialised services and support for 5,000 people in Warrington, where and how is the decision being made about the total resource available for the Warrington population?

As we move to greater specialisation focused on a small number of providers, how do we have the conversation about the less specialised needs of our local populations? This can only be done by CCGs and specialist local area teams working together.

Criteria for succes

However, the history of primary care trusts and strategic health authorities trying to work together to address similar issues did not have a great track record. What are we going to do to make this happen in the new, even more complex, environment?

We all know service reconfigurations cause much public concern − everyone wants the best services, but everyone also wants them provided in their local hospital. Local politicians rarely support changes that result in local service loss even when the evidence clearly shows the service change will improve quality for the patient when delivered at another locale.

‘We cannot risk things getting lost in translation and we must ensure we hold on to this opportunity to do things differently

We now have an even greater number of interested parties to bring together. We have to make sure the conversation always focuses on how we commission and deliver the best possible care for patients, that we consider pathways of care and systems of care, and that organisational sovereignty issues are secondary.

The criterion of success must be provision of an integrated health and social care system that overall is sustainable, not maintaining the sustainability of every individual existing organisation.

The local area team commissions neonatal screening and childhood immunisations and, for 2013-14, health visitors − a key element of our children’s service transformation programme. Other components are commissioned by the CCG and local authority. We have not yet calculated how many people will need to be in a room to commission the whole children’s pathway.

Integrated commissioning

In Warrington we have invested considerable time and energy into developing relationships with our local authority, both elected members and officers. We have a joint post leading integrated care commissioning, supported by a team that is growing and deepening the shared remit.

With the development of the personalisation approach, we have seen the need to begin to separate “micro” person-centred commissioning of care packages from “macro” whole-service commissioning. The commissioning of social care and personal support for individuals is as critical to health and wellbeing as clinical health interventions. Every part of the pathway − whether commissioned by NHS England or the group − has to include this element.

The presence of the local area teams as members of the health and wellbeing board provides us with a governance model, but it is having systems in place to actually make change happen through co-commissioning, co-procurement and co-contracting that is going to be critical.

Andrew Lansley’s original vision was of a simplified system with primary care clinicians leading the commissioning of services. I and my colleagues in Warrington CCG are absolutely committed to improving the health and wellbeing outcomes for the people of Warrington and we already have a track record of doing so during the fluidity of the transition.

However, the process of writing this article has caused us to question whether we will continue to be able to do so as the new system hardens and sets. We cannot risk things getting lost in translation and we must ensure we hold on to this opportunity to do things differently.

Dr Sarah Baker is chief clinical officer at Warrington CCG, which received the 2012 HSJ Award for commissioning organisation of the year