Aimed as a stepping stone to shifting care out of hospitals and into the community, the move towards co-commissioning primary care will affect local health services in different ways

Bridgegate in Rotherham, South Yorkshire

Commissioners in Rotherham believe they are in the best position to make primary care commissioning decisions for the local area

Rotherham CCG: Overcoming conflicts with a “federation” model

Having the powers to shape local solutions to problems facing the local health economy was the key reason behind Rotheram’s decision to take on co-commissioning.

According to CCG chief officer Chris Edwards, another motivator was the loss of personal medical services premium payments – expected to amount to £2m a year – and that could have affected the viability of up to a third of the CCG’s 36 member practices.

However, NHS England chief executive Simon Stevens has now said that this money will remain within local primary care, giving the CCG an opportunity to devise solutions that relieve pressure on those practices and keep the services going.

Now the organisation feels it is in a good position to be a local commissioner.

“We have the relationships locally; there will be winners and losers in terms of practice income. We can do that sensitively and understand the situation,” says Mr Edwards.

‘Budget is “the elephant in the room” for many CCGs, but Rotherham can probably manage – it is spending slightly less than its £25 per head allowance’

Practices in the area are setting up a federation that may offer support to practices through buddying schemes as well as picking up some work coming out of hospitals.

Mr Edwards still expects that there to be financial losers among practices but says there will be a very transparent process around this.

Rotherham is planning to appoint a third lay member and set up a primary care subcommittee which will be advised by GPs but will have no GPs on it – it will be made up of lay members and senior CCG officials (proposed to be Mr Edwards, the chief nurse and the chief financial officer). Papers will be co-written by key officers and GPs.

This will help it overcome the conflict of interest issue that co-commissioning could create but, Mr Edwards concedes, it is still arguable that GPs will have influence on the subcommittee through their advisory role. However, other alternatives – such as outside advisers – would be costly.

The CCG has applied to take up full delegated powers from next April. It has already taken on four additional staff to enable it to do the work around co-commissioning.

Will taking on primary care commissioning mean breaking through the management cost ceiling? Budget is “the elephant in the room” for many CCGs, suggests Mr Edwards, but Rotherham can probably manage – it is spending slightly less than its £25 per head allowance so has some room for slippage but other CCGs may not be in the same situation.

The other danger is that primary care commissioning may swamp the CCG and take up a lot of board time –something Mr Edwards is very conscious of. He also points out that when it comes to renegotiating national contracts, it is not clear what involvement or voice CCGs will have.

In the longer term, the CCG might be interested in commissioning community pharmacy.

“We could do it and add value by having local knowledge of the issues,” says Mr Edwards.

But he adds that the CCG is in an unusual position: it is coterminous with the old primary care trust with many of the same people running it. Its local medical committee is quietly supportive of it taking on commissioning. Other CCGs will have had a different task and will be in a different starting point.

Hull CCG: employing sdiferentiated pay packages

Hull CCG could develop different payment packages for GPs if its plans to take on delegated powers for co-commissioning in April succeed. Chief officer Emma Latimer hopes it will enable the CCG to better meet the healthcare needs of the area.

The new models will be voluntary but around a third of GPs in the area have already expressed an interest in moving away from their current contract. The area has 57 practices, around 30 per cent of which are single handed.

“There’s a strong sense that something needs to be done differently,” says Ms Latimer.

She adds that it is about delivering better primary care rather than the practices taking on community contracts.

‘We are looking to move from a loose collaborative in primary care to an accountable care organisation’

“We are looking at long term conditions and episodic care and splitting the two into a different model,” explains Ms Latimer. One option would be employing some salaried GPs. Any new model of care would operate in shadow form initially.

“We have people in premises which are very old buildings,” she says. “Some of the older GPs are frightened – they are stuck with a contract that does not help.

“We want to move some of these people out of single handed practices.”

The new powers would help to drive some of the changes the CCG wants to see, such as the community hubs it is developing.

“We are looking to move from a loose collaborative in primary care to an accountable care organisation,” says Ms Latimer.

‘Some of the older GPs are frightened – they are stuck with a contract that does not help. We want to move some of these people out of single handed practices’

This would involve spending more of the budget in primary care, focusing on outcome based contracts that reward quality with a shift in resources out of secondary care.

Other aspirations include a seven day a week approach from GPs. Ms Latimer says that she would like the CCG to eventually go further and become involved in commissioning other services such as public health.

To achieve this the CCG has had to increase the involvement of its three lay members. Ms Latimer says that primary care is so much of a priority for the organisation that it is determined to take the opportunity to co-commission even though details such as additional management funding are still sparse.

“The local area teams did not really have the capacity and capability to commission primary care,” she says. “It has been quite fragmented. We think by having the primary care budget and a different model, we may be able to attract people to GP jobs.”

Gerard Hanratty on the future of primary care

On 10 November Next Steps Towards Primary Care Co-commissioning was published. The document provides far more detail on the various options for co-commissioning being offered to clinical commissioning groups and sets out a timetable for each CCG to assess which option will suit it best.

That assessment will depend on a range of local factors and the decision is likely to be central in determining the extent to which co-commissioning can support a CCG’s wider aims and ambitions. The new guidance gives CCGs an opportunity to look afresh at which option they wish to adopt: greater involvement in primary care commissioning; joint commissioning; or delegated commissioning.
When a CCG decides to opt for joint commissioning or delegated commissioning it will be required to complete a pro forma for NHS England by 30 January or 9 January respectively. In making the decision two critical issues arise for CCGs to consider:
First, which co-commissioning option best suits my CCG?
In addressing this question, a CCG will need to look at its strategic direction and consider such factors as:

  • The potential for co-commissioning to facilitate delivery of its aims and ambitions to improve patient services and outcomes in its local area. This will also need to take into account surrounding CCG collaboration and the how best to optimise the ability to shape the local health provision to the local health need.
  • The support of the CCG membership will be essential. Many GPs have asked for this enhanced role and ability to truly shape local health economies - this will be their opportunity to lead in developing new models of health provision.
  • The extent to which additional sums for reinvestment in primary and community care might be made available in the CCG’s area - for example, through a personal medical services review.

Second, what governance changes, including to the constitution, do we need to make?

Many CCGs are now looking at their governance arrangements and how they need to shape themselves to take on these additional commissioning functions. They now have a great opportunity to shape their structures, following a year of commissioning, to give a flexible platform on which to commission improved services for their local communities. Certainly, a common feature of successful CCGs to date has been the adoption and development of governance structures that meet their specific circumstances.

The co-commissioning agenda presents CCGs with a real opportunity to drive the development of the future health service in England and start to implement the ideas put forward in the NHS Five Year Forward View. In order to do that CCGs need to look at their commissioning structure to provide a strong platform on which to join up out of hospital and in hospital care, so that patients can get improved benefit from the services their local NHS offers. Taking on responsibility for primary care commissioning will let them start to develop that future vision.

Gerard Hanratty is a partner at Capsticks.

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