What NHS England isn’t telling you, and more indispensable weekly insight for commissioners, by Dave West

Five messages from CCG leaders

We had a very strong response to HSJ’s spring barometer survey of clinical commissioning groups’ senior leaders, which is great news for getting some clear messages from it. Thanks to the chairs and accountable officers who took part in this important sounding board.

I see five big themes in the findings:

1. Pandora’s Box: The survey, done with support from PA Consulting Group, confirms many commissioners want to put contractual, governance and organisational models in place to support integrated care and whole system management. More than half of CCG leaders (58 per cent) expect to form an “accountable care system” over the next year to 18 months; and 55 per cent expect to put in place new “alliance” contracts. More than 35 per cent expect to adopt the new GP contract for large scale providers; and more than one in four expect to establish an “accountable care organisation”.

There has long been a latent desire for these types of approaches among local NHS leaders in the belief they will support joined up, prevention-focused services, and sometimes a perception they involve more collaborative leadership. So perhaps it is little surprise that the floodgates have opened in response to national evangelising for “whole system” sustainability and transformation planning, the new care models programme, and official support for examples like Northumberland’s planned “ACO”.

What is not clear is whether officialdom can keep up with – or is supportive of – such a widespread shift.

Many commissioners responding to the survey indicated that help and support for these reforms was absent; and/or called for NHS England and NHS Improvement to back it with their own behaviour.

One AO said: “Increased system working and collaboration requires a changed approach from the regulators not just local organisations.”

As far as national encouragement goes, NHS Improvement chief Jim Mackey issued a strong warning last month against chasing “trendy” changes to institutional or financial structures as a cure-all solution to the problem of integrating care. He referenced the collapse in February of Cambridgeshire and Peterborough’s “outcomes based” capitated contract, which has led to various national inquiries and slowed down other tender processes. This clearly won’t nix all attempts in the very broad categories outlined above (after all, Northumbria is Mr Mackey’s home trust), but there’s a sense that national leaders feel they have opened Pandora’s Box.

That said – and as PA Consulting Group’s John Rooke discusses – the barometer also shows CCG leaders prioritising “shared ethos and values” and “effective shared leadership” alongside “shared governance structures” as a means to achieve integration.

2. Who will step back: The survey asked about the impact over the next year to 18 months of the creation of STP footprints.More than a third of respondents believed “STP leaders will become responsible for performance and finance across the footprint”– showing an expectation that the STP leader role will broaden substantially. Sixty-eight per cent said they personally would work to set strategy across their whole STP footprint. Only one in five believed “some CCG leaders will step back from setting strategy across the CCG-area health system, as the STP lead takes this role”.

That suggests there will be a lot of chairs and accountable officers, in commissioners and providers, seeking to lead and develop strategy across the same patches. Not unworkable, but it may be a messier picture of responsibility and accountability than has gone before.

3. Financial confidence: As discussed previously in The Commissioner, some CCGs arefeeling the strain on their bottom line more than they have in the past.

“Virtually all our levers to deliver a balanced budget have now been taken away,” one AO stated. It’s worth pointing out – as some have to me – that CCGs have been anything but oblivious to the NHS’s financial problem thus far. Some are or have been in deficit, while the large majority spend lots of time dealing with the consequences of severe spending constraint and big efficiencies for their populations and health economies.

This is neatly illustrated in a map my HSJ colleague Lawrence Dunhill has produced, showing that all but one STP areas are running net deficits across the whole health system. This is not exactly the same, though, as commissioners themselves are running a deficit, and the spread of the latter may drive a different approach to savings.

4. Targets for savings: The survey gives us an overall flavour of the main areas being looked at, or methods being used, to find efficiencies. The two categories of redesigning out of hospital services with a view to delivering savings, and significantly reducing hospital activity, are seen as very important and have been in previous CCG barometer surveys too. An addition to very popular options this year is a substantial focus on reducing treatment rates (linked to this year’s compulsory RightCare push?).

5. Savings vs relationships: The fact that there’s a widespread intention to significantly reduce hospital activity sits intriguingly, or perhaps uncomfortably, next to the survey’s finding that CCG leaders are prioritising collaborative, consensual approaches to commissioning: Improving relationships, convening NHS leaders and reshaping incentives are rated highly, while only one in 10 see “applying existing levers and incentives” as very important.

It also points to one of the big problems facing those working on whole system planning, which has bedevilled planners before them. That is to reconcile the desire, particularly of commissioners, to plan for ambitious reductions in acute and tertiary care spending growth and the inclination of providers to plan for what they believe is the likely continuation of growth. 

Perhaps it’s wrong to think about strategic planning (running this year through STPs) in such a transactional way. But I can’t see, for example, how the funds promised for primary care over the next few years in the General Practice Forward View will become real without big changes to the trend in acute spending.

This week in primary care

The General Practice Forward View has been published by NHS England, which obviously has a lot to say about GPs while not being very keen to commission them directly. A couple of observations:

  • More than a fifth of the funding growth promised for general practice in the document is not accounted for in NHS England’s allocations for primary care fixed in December. The national body is refusing to say where it expects the rest to come from, but it seems likely to rely on local decisions to invest in primary care. We are still pressing for detail.
  • The strategy puts the need to calm down the GP workforce ahead of describing how primary care will be improved, expanded and joined up with wider services in coming years, or setting out how this will be achieved.

Dave West, senior bureau chief

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