The Commissioner: New commissioners - an ACS leader

This is the start of an occasional series in The Commissioner hearing from people whose roles or organisations are new, or undergoing a lot of change. This week, we have Dorset Clinical Commissioning Group chief and accountable care system lead Tim Goodson. He is by no means new to commissioning, having worked as chief officer since 2013 and as a director in primary care trusts. But the CCG’s role is changing substantially as the health economy, having previously agreed a major plan for service change, is now making headway as a first wave “accountable care system”.

Working as a system

Tim Goodson: “The change has allowed the system to think as a system, versus just taking care of your own organisation. You can see that people are trying to see things from other parts’ point of view. It is a mindset change.

“One thing that’s important is have you got sign-up right at the very top – with the chair and chief executive? That is a powerful statement and allows people underneath to see that’s the way it’s going.

“The strength of our ACS is the leadership within the different organisations wanting to do it… If someone sees themselves as more isolated, you would struggle to implement any of this.”

Benefits of being an ACS

“You get a bit more autonomy [and] we are getting good access to the senior people within NHS England and NHS Improvement.

“The ACS group meets effectively monthly and the national directors are coming along and championing it, sometimes with Simon Stevens [or] Jeremy Hunt, and we have had access to people from Number 10.

“If something is not right we can speak up and someone will say: ‘If we can correct it we will’. They find ways through. If it’s within their remit they will unpick it and give you the headroom to do it.

“It is encouraging and quite different. Your conversation with regulators is not just one about performance and pressure and ‘why aren’t you doing more?’. It is a refreshing change – it is ‘how can we help you?’

“It’s one of the best experiences I’ve had since I’ve been involved in the NHS. It really feels like everyone is trying to pull in the same direction.

“We asked: can we negotiate our control total across the system, one provider to another? That is now going into action with the option to formally offset one provider’s position with another.”

Role of the CCG

“It changes the role of the CCG, especially because we are coterminous [with the ACS].

“We are very much moving out of the CCG to be a system enabler. A number of team members are working in the trusts, out in the system. We are reconfiguring some of our structures.

“It is changing the way people think too: ‘Let’s be part of the system. Let’s spend as much time with the providers as opposed to looking in, performance managing’. That then changes how the system looks at the CCG.

“We are being asked to be more self-assuring as a system and take on some of the functions that NHS England and NHS Improvement would have undertaken.

“A small number of staff are coming across to work with the CCG from NHS England, though they’ve been bringing their workload with them, but it’s a step in the right direction.

“The nearest NHS England team is 30 miles away, which makes staff support difficult for us, but there has been flexibility in this area where we’ll employ the people locally when a vacancy has arisen.

“It has been useful for engaging with the local authority. In the past the relationship felt a bit distant. The [review work] and sustainability and transformation plan brought them in and the ACS took it further. Health and wellbeing boards saw ‘we can do this – things like prevention at scale, and wider health determinants’. It has given them all a good purpose to get things going.

“[However], the ACS and STP have come down through the NHS side. They are not really coming through local government side. Local authorities are doing this because they want to – you ideally need the [signal] coming down both sides, not just one. Jeremy Hunt’s wider role [leading the social care green paper] hopefully will help with this.”

Future for ACSs

“We [the eight first nominee ACSs] are a group that’s been pushing ourselves and is generally higher performing. That’s the group you’d go with first.

“It is useful having quite a tight group at this point. If the group was bigger from day one, you wouldn’t have the [quality] of the conversation that we’ve had.

“There are no instruction books on how to do this [and] that type of change wouldn’t suit everybody. The infrastructure is still not set up to do this – things like foundation trust governors and the Competition and Markets Authority. It’s about finding a way through this.

“Other [areas] will have taken the steer and I’m sure there are others who are equally as advanced.

“We have got to know some of the ACS group, got one on one time with people. If they are going to mainstream it, at some point the balance will tip. At the moment, that would feel too early.

“Ultimately if this is going to be embedded at some point there will need to be a change to the legislation.”