Can CCGs find a role in the NHS’s efficiency challenge?

What will clinical commissioning groups do to help with the massive NHS cost savings effort required over the next 18 months?

Doubts have been simmering away about the purpose of maintaining 209 CCGs for some time, and if this question can’t be answered convincingly then commissioning’s crisis of confidence and identity will soon reach boiling point.

The timeframe matters because financial performance in the next 18-24 months will be decisive. A Department of Health overspend this year or next is entirely possible; this could result in a dead end for the NHS Five Year Forward View vision and constant disruption to national policy.

‘If this question can’t be answered convincingly then commissioning’s crisis of confidence will soon reach boiling point’

The question of CCGs’ role in the immediate financial challenge was debated by some of the sector’s wisest heads at HSJ’s Commissioning Summit last week.

It was clear that most of CCGs’ substantial energy and influence is going into reshaping primary, community and social services; including reforming provider models, and working outside the NHS to build health and resilience. This is critical work and many have a good chance of success. The problem is that most resulting savings, through curbing secondary care demand, will not be cashable in the next 18 months.

CCGs’ greatest resource and unique strength is their direct connection to influential clinicians in primary care, predominantly GPs. National NHS officials have noted this but have not made the most of it. It can be harnessed to help the efficiency effort.

Identify and accelerate

First, commissioners should be challenged to identify and accelerate the changes in primary and community care that will offer meaningful cash savings quickly. New pushes on referrals and prescribing, informed by variations in practice, over-treatment and non-medical alternatives, have potential. So do stopping admissions from care homes and better support for hospital discharge.

Local responsibility for primary care, and its impact on total healthcare cost, would be reinforced by NHS England handing nearly all CCGs their general practice budgets overnight, instead of hampering the co-commissioning transfer with difficult sign-up deadlines. This would be unpopular with some but most CCGs would improve on the current creaking apparatus.

Push through change

Second, engaged clinical leaders in CCGs are willing to champion major changes to services and estates that can save cash, and have a better chance than most of winning support for them. This capability could be used more often and more effectively.

Primary care leadership can be called on to help with consolidation of specialist services, which NHS England has long promised, but in most areas not delivered. Some commissioners are developing realpolitik methods of tying local politicians to potentially unpopular cuts by offering them more strategic control and the chance to join up services under devolution deals.

‘Engaged clinical leaders in CCGs have a better chance than most of winning support for major changes to services’

Third, commissioners have had little involvement so far in NHS trusts’ conversations about cost cutting driven by the Dalton review of provider forms and Lord Carter’s work on productivity. CCG leaders could be expected to sign up to providers’ response to these, and use their levers to help make it work.

Fourth, it is a routine complaint but worth retelling that NHS England and the regulators could save both their own costs and those of their charges by trusting them more, and cutting back on repeated, conflicting and usually futile requests for assurance information.

Finally, clinical leaders who stay at arm’s length from cost cutting on their patches will lose the opportunity to spot and prevent measures that pose too great a risk to care quality.

Apart from the damage to patients and the NHS, if there were one thing guaranteed to seal the redundancy of local commissioning, it would be the failure to notice the next burgeoning care scandal.