Commissioners must work together to mitigate risk

At a time when the tide is turning for providers to move from competition and choice to integration and collaboration, the commissioning system looks increasingly fragmented. 

‘We need to develop plans that make sense for the whole country and each of the 211 CCGs’

If we genuinely believe those patients who are the most complex require providers to work together, then we equally need commissioners to work together designing bespoke solutions for individuals and populations. If commissioners do not work together then we will all face significant service, financial and political risks.

Clinical commissioning groups need to work effectively with local authorities, their neighbouring groups and NHS England. In north east Lincolnshire we have excellent relationships with all of our key partners but like other areas we are working through how we can align our plans to mitigate our collective risks.

Working with our local authority

We have inherited a unique partnership arrangement with our local authority. Since 2007, the local NHS has been responsible for commissioning adult social care on behalf of the authority. We believe we are the only CCG in the country that can plan services for individuals and communities to address both their disease and care requirements. This has brought real advantages for individuals. Improved outcomes include significantly lower hospital admission, the second lowest hospital readmission rate in the country and long term residential care placements at 6 per cent below the national average.

Like every local authority in the country, we are being asked to make unprecedented savings from our adult social care budget at a time of significantly increased demand from our elderly population. The scale of the savings will have an enormous impact on individuals and their families, as well as the local NHS budget.

We believe more patients could be admitted to hospital, take longer to be discharged and be more likely to be readmitted. Despite the significant risks for the CCG we believe that as an integrated health and social care commissioner we are well placed to mitigate these risks through the deployment of our collective resource.

‘The culture between CCGs, local authorities and NHS England feels right to deliver solutions that make sense for each community’

Our greatest resource is our workforce. In order to help mitigate some of these risks our social work professionals are establishing their own practice, which will sit alongside general practices on our council of members. This practice will develop the profession of social work. It will act as an advocate for individuals and communities with complex care requirements. It intends to develop more resilient communities that can help one another.

Finally, it hopes to create an environment in the borough to spread the risks borne by the public sector through extending the concept of citizenship to individuals, the voluntary sector and corporate bodies.

At the same time adult social care was transferred to the local NHS, the commissioning of children’s services and public health was transferred to the local authority. This is starting to deliver improved outcomes where lifestyle is a significant contributor to health. Examples include one of the lowest perinatal mortality rates in our region, significant reductions in teenage pregnancy and early deaths from cardiovascular disease.

We are concerned that we have a shared risk of unsustainable dependency on public sector services. We are working together to develop the partnership to promote independence through areas that we have direct control or influence over such as housing, leisure, skills and employment on improving health outcomes.

Working with our neighbouring CCGs

The north of Lincolnshire has some real challenges, given its rurality and relatively small populations, to maintain effective, high quality, accessible, affordable services. We have been working with our neighbouring CCGs to develop plans that make sense for the whole region. We share a collective risk that we may not be able to secure comprehensive services from each of our areas.

As statutory bodies responsible for our own localities this creates an inherent tension that is difficult to reconcile. We have appointed an independent chair and external programme support to help resolve this inherent tension but ultimately believe that NHS England will have to take a strategic and system management role to manage the risks for the whole population affected.

Working with NHS England

NHS England has potentially conflicting roles in this new system creating inherent risks that need to be managed with the CCG community:

• planning and priorities;
• direct commissioning;
• assurance and delivery; and
• system management.

We need to develop plans that make sense for the whole country and each of the 211 CCGs. Plans should not exclusively favour NHS England’s responsibilities.

NHS England’s direct commissioning needs to align with those of each CCG and to adopt an approach that holds its own commissioning arm and CCGs equally to account.

It needs to adopt an approach to manage the whole system in a way that respects the sovereignty of individual CCGs without creating unreasonable inequalities of access and outcomes.

As leaders of the new commissioning system we have a real challenge to work together to design plans for the population we serve. The culture between CCGs, local authorities and NHS England feels right to deliver solutions that make sense for each community in the country. The real challenge is that if providers and commissioners are to be successful in developing plans and delivery mechanisms to address the inherent risks in the system then we will also need integrated approaches to external regulation and assurance.

Dr Peter Melton is accountable officer at North East Lincolnshire CCG