Commissioning support units have a potentially valuable role to play in delivering large scale service change with CCGs, say Derek Felton and John Farenden

Turning over a new page

CCG leaders are still burning with energy and enthusiasm to drive change

As the new financial year looms on the horizon, it is time to reflect on the challenges that face commissioners as they work on future plans.

‘No trust is going to simply grow their way out of the problem’

Everyone Counts sets out a tough test for commissioner led improvements made to patient outcomes and services. It also calls upon clinical commissioning groups to look into the future and develop five year strategic plans.

While it is right to plan over a longer term timescale – as it takes time to change clinical pathways, rebalance the workforce, improve the estate and invest in technology – it is a huge task, especially for the smaller CCGs.

The planning challenge

They have to form the alliances, engage the population, empower the clinicians, align the incentives, pull the change levers and deliver the ambition – all within an environment where the scale of financial challenge has huge implications.

No trust is going to simply grow their way out of the problem and many face the prospect of significant cost reductions in many areas of healthcare delivery.

It means providers have to deliver better patient outcomes and be financially stronger at lower levels of income. Commissioners have to recognise that and show leadership in bringing about whole system change.

They need to facilitate change programmes that deliver both cost reductions and outcome improvement. 

To be honest the track record of commissioner led change to date has not been great.

Best practice change management techniques are rarely used and when change is introduced, it is rarely sustained and benefits wane.

Harsh history lesson

If you think this is harsh, let us reflect on what we have learnt from the past. Historically the NHS has overrelied on confrontational contracting rather than aligning incentives and outcomes.

Best practice change management suggests that change happens faster and more reliably when there is something in it for everyone, even if some compromises have to be made along the way. No winners and losers; everyone has to share the pain and gain.

‘We regularly construct endless lists of unsustainable QIPP schemes that are unmanageable, unrealistic and too numerous’

The annual contracting cycle and associated quality, innovation, productivity and prevention planning has become the means of enacting commissioner led change when logic suggests it should be less costly, less complex and a simple documentation of a continued relationship.

We need a more honest and more effective set of commissioning constructs and change levers.

We regularly construct endless lists of unsustainable QIPP schemes that are unmanageable, unrealistic and too numerous to be supported by clinical leadership. We then wonder why they do not deliver their potential. Strangely, despite this, some sort of financial balance is often achieved.

We do not use the full range of change levers available to clinical commissioners, but seem content to use the unsuccessful tactics of ancestor organisations.

When the scale of change increases we look for larger, more ambitious and longer term schemes that are more easily threatened by political mood and multistakeholder paralysis because the leaders of change cannot align all the incentives to secure consensus.

We use a “fire and forget” model of commissioning. We launch a new pathway but do not maintain the discipline of performance management that ensures the benefits are sustained through to established evaluation and measurement techniques.

The NHS could be accused of arrogance in designing and adopting a new model of change management that is at odds with evidence based, tried and tested techniques used in other sectors and then wondering why change does not stick at the scale and depth that is required.

Times of change

We have a new commissioner landscape of CCGs and commissioning support units that is slowly leaving their turbulent transition period only to find that the idea of a period of stability is still as far away as ever.

We have a five year change window that enables systems to be bolder and we have a policy of enabling greater integration across health and social care, which offers huge opportunities for creative and imaginative thinking. However, at the same time this hugely adds to the complexity of balancing national policy with local priorities

Some larger CCGs will want to tackle challenges themselves and may have the size and scale that gives them the option, but even the largest will recognise that many issues require collaboration across a wider footprint.

Even some of the larger planning units may be too small for some of the toughest discussions around wider reconfiguration of providers which will be needed to cope with the scale of service change required.

CSUs have a potentially valuable role to play in this. If they can put parts of their history behind them and gain the trust and respect of their customers and their partners, they have the opportunity to become honest brokers across a health and care economy. 

‘CSUs have the opportunity to become honest brokers across the health and care economy’

They can recruit top commissioning talent – freeing CSUs from hierarchical management – and deploy their value across wider geographies than ever before. 

The very raison d’être of CSUs encourages them to professionalise commissioner led change so they can demonstrate value, win business through reputation and invest in the talent for even more valuable outcomes and benefit for their customers.

There are many examples of clinical commissioners connecting with provider clinical leaders to shape new pathways, improve outcomes, and reduce cost and waste. These examples are not part of a paralysing annual contracting cycle; they are common sense case studies in “real time”. Challenges do not start and stop on 31 March.

We know that major structural change and horizontal integration rarely delivers the expected benefits given the time they take, the threats to competition scrutiny, the management costs of sustaining them, the risks and threats to their continuance and difficulties maintaining buy-in.

However, we also know that when we take time to align incentives, aim for improved outcomes and value early delivery, we can increase the probability of successful change programmes.

Radical does not have to mean organisational and structural change and an increase in the number of unrealistically large multi-stakeholder system reform programmes.

How to deliver radical change

  • Reward and recognise leadership performance, not by achievement in individual organisations but by the success achieved by the system as a whole.
  • Simplify the annual contracting cycle rather than complicating payment mechanisms.
  • Deploy imaginative, realistic, outcome based commissioning techniques rather than simply reinventing contracting based on outcomes.
  • Increase the contribution that clinical productivity and performance improvement can make and reduce the number of QIPP “schemes” that CCGs pretend they can achieve. Do a few things really well rather than fail heroically.
  • Recognise that a valuable skillset of commissioners is an “incentive alignment” and can therefore be a valued CSU service proposition worthy of investment and promotion.
  • Evaluate the success of QIPP through the achievement of individual programmes and their impact on patients rather than through the overly simplistic metrics of achieving overall financial balance or the volume of savings realised.
  • Recognise that commissioning is about change management and using well formed and proven techniques that should be used to achieve success.

The five year health system strategic plan provides the opportunity for system leaders to come to the fore, recognising the realities of the new NHS.

Those systems leaders, wherever they come from – commissioners, providers or local government – have the opportunity to create a new consensus and a health system that is more appropriate, more aligned and more popular.

‘There will be hard decisions and compromises that have to be made; not everyone will come away with everything they want’

There will be hard decisions and compromises that have to be made; not everyone will come away with everything they want. Ultimately, it must be safe for patients and avoid a variation of previous incarnations of integrated plans which hit the targets but missed the point.

Some might see this as reflecting a “we’re all in this together” mindset but perhaps it could be better put by altering J.R.R. Tolkien’s The Lord of the Rings quote: “One plan to dream for all, one plan to drive them. One plan to bind them all and in the bleakness unite them.”

Derek Felton and John Farenden are leaders in EY’s commissioning team