Oxfordshire battle will determine the impact of CCGs

One of the most pressing decisions Simon Stevens will have to make when he takes over as NHS England chief executive in April is how far he is prepared to back clinical commissioning groups acting as disruptive innovators in their healthcare economies.

‘Disruptive plans are going to struggle for political backing in the immediate run-up to the election’

This week HSJ reports on the standoff between Oxfordshire CCG and its main acute and mental health providers. The CCG wants to move rapidly away from activity based contracts to ones organised around, and paid on the basis of, outcomes.

This is just one of many such tussles across the country, in areas such as Northumberland, Cambridge, London and Surrey. But the battle in Oxfordshire is the one attracting attention at the centre.

Spooked providers

This is unsurprising. Oxfordshire CCG is one of the largest commissioning groups and in Stephen Richards − the brother of Sir Mike − it has a confident leader. Ranged against him is an éminence grise of the provider sector, chief executive of Oxford University Hospitals Trust Sir Jonathan Michael, and Stuart Bell, the only mental health chief executive to regularly appear in the HSJ100 “power list”. The COBIC consultancy methodology that the CCG want to exploit was in part developed by former Tony Blair adviser (and Simon Stevens confidant) Paul Corrigan and has been championed NHS England’s Bob Ricketts.

Oh yes, and David Cameron happens to be a local MP.

‘The lesson from this tale is how far CCGs have to go to get noticed’

The way the story has unfolded is illuminating. The providers initially seemed to be untroubled by the CCG’s radical plans. This clearly changed and the two provider chief executives sent a letter that − in restrained NHS management speak − attempted to rubbish almost every detail of the plan; warning of dire consequences should it be implemented.

The tone of the letter suggests the providers were genuinely spooked by the plans; an unusual position for these powerful incumbents. But − to date − their tactics appear to have worked. The plans have been rolled into the longish grass. While the CCG declares its intention to pursue its proposals, the providers know time is − almost always − on their side.

Disruptive plans are going to struggle for political backing in the immediate run-up to the election and should Labour win, CCGs are likely to see a significant reduction in their influence − and providers a considerable increase.

Implied threat

The other lesson from this tale is how far CCGs have to go to get noticed. The implied threat in the use of outcome based contracts is the introduction of new providers. It is instructive of the relatively weak position of even one of the biggest CCGs that it chose to raise this spectre in order to be taken seriously.

Ambitious CCGs are unlikely to get very far without central backing. NHS England under Sir David Nicholson has prioritised maintaining stability through a period of change.

‘Simon Stevens will want to support whoever has the best chance of making desirable change happen’

The delicate nature of the NHS’s finances and emerging threats such as accident and emergency waits mean many in government are grateful for that approach and would agree about the danger of moving too fast in adopting a relatively untried system.

But there are others in influential positions who are asking what the reforms are for if not to empower commissioners to challenge existing provider models and to relatively quickly switch the focus to measures that more directly reflect care outcomes. They are also keen for NHS England to be more active in support of these aims.

Mr Stevens will listen to the lobbying with a pragmatic mindset; he will want to support whoever has the best chance of making desirable change happen. But he will also know that “defeat” in the battle of Oxfordshire and other high profile confrontations will strengthen the view that clinical commissioning has limited prospects of making a real difference.