Finding the way forward

As the ink is yet to dry on the map of clinical commissioning groups we embark on the perennial debate about the optimal commissioning zone for NHS services. Like the UN Security Council, the undertone and anticipated solution is predicated on the imposition of size, influence and power.

The NHS Commissioning Board is actively encouraging CCGs to consider their arrangements for commissioning collaboratively in advance of the 2013-14 “contract round”. This advice and pre-authorisation expectation is formalised in the draft framework released in August. Take heed aspirant CCGs.

The benefits of collaborative commissioning, including traditional “lead commissioning”, are well known - focus, local knowledge, relationships, division of labour and purchasing power.

The path to unlocking the benefits relies on the partners setting out what they wish to achieve, the risks they seek to avoid and with which partners they can best avoid them.

The reputation and track record of “lead commissioning” is mixed. Admit it - the majority of us commissioners believe our lead commissioning was great and the work done by our neighbours was less so.

The provider’s perspective of this was probably the converse, with the view that the benevolent and supportive commissioners existed just over the border.

Having witnessed a situation in which a lead commissioner resolved its financial risk with a provider literally at the vast expense of its neighbours, the arrangements have not always been collaborative or offered effective risk sharing. Moreover, the NHS’s internal market environment has not produced too many occurrences of the monopoly being suppressed by the monopsony.

End of the monopoly

The birth of the membership organisation, personalisation of services and outcome-based commissioning for the population means that the traditional, unilateral focus and accountability for the main acute provider becomes untenable.

Those clinicians whose patients did not happen to use the main provider in a primary care trust area were often disillusioned by commissioning and the lack of focus on their registered population. Alienated followership is one outcome a CCG can ill afford.

CCGs will seek protection from financial rainy days in each other’s company, especially as the profile of their budgets - with the possible exception of specialist commissioning - is arguably more risky than those of its predecessors. The financial shelter sought by the risk pool will include:

• partnering with CCGs in control of their acute activity and those which deliver against their quality, innovation, productivity and prevention plans;
• creating larger populations to dissipate unforeseen shifts in activity and/or cost;
• understanding liabilities against any individual CCG budget surplus, including supporting system-wide financial balance.

Trust and bravery are required to leap into such arrangements. As we wait to experience the formal and informal responsibilities of CCGs in supporting transition and local system financial balance, a set of uncertainties remain that may, in the early years, make formal risk pooling the exception rather than the rule.

The NHS Commissioning Board is right: CCGs have a duty to put in place formal arrangements that enable the commissioning process to represent all those who access the services, regardless of the CCG in which they reside. Critically, these arrangements are underpinned by the contribution of the collaborating CCGs to offer the positive contribution of clinicians and members of the public to the assurance and development of quality and value offered by providers.

In my area, the Bedfordshire, Corby, Luton, Milton Keynes and Nene CCGs are collaborating to lead a programme called Healthier Together. This is a review of how healthcare services are provided across the southern East Midlands and in its five hospital trusts (Bedford, Kettering, Luton and Dunstable, Milton Keynes and Northampton). Led by GPs, hospital consultants and health professionals working with patients and local people, the review builds a view of how services should be developed to improve quality, safety and outcomes.

Collective commitment

The excellent work to date, while supported by a concordat between the commissioners, is driven predominantly by the collective commitment between the clinicians, providers, clinical commissioners and patient representatives.

Jumping continents, Massachusetts, in the US, has one of the most expensive healthcare systems in the world, which produces a financial and system reform challenge unrecognisable to us disciples of the Nicholson challenge.

The approach of forming larger and larger buying groups in an attempt to impose their will on local providers is not serving the US insurance companies or the taxpayer well. Mount Auburn in Cambridge provides an example of where the formation of an accountable care organisation is making a big impact on the affordability and quality of healthcare.

The Independent Physicians Association, covering just 500 doctors, has taken its formula-driven, population-based budget from the insurance companies (much like a CCG from the commissioning board). The clinicians leading these organisations have shared the risk - and, importantly, the benefits - of the budget with their local hospitals. Where quality is excellent, the insurance company offers a performance related bonus, which is shared by all local clinicians, as income, in proportion to contribution.

The Mount Auburn clinicians, from both hospital and community environments, set a common purpose of quality improvement. The community physicians support their local hospital by referring - with lower levels of variation - their patients to its services reducing “leakage” elsewhere. The hospital, in turn, does not overproduce.

Where quality is insufficient, the clinicians quickly collaborate to resolve the situation before, for example, community physicians seek alternative hospital provision for their patients. The alignment of purpose and incentives, supported by an environment of effective clinical leadership and challenge, creates greater sustainability in the local system.

While we diligently enter into legal arrangements with our fellow CCGs in a misguided quest for stability across multiple challenged systems, it is worth considering that the strength and resilience we seek may be better found through collaboration with the local community and clinicians of all persuasions. Relationships and alignment, not size and power, are the currencies for risk register colour transformation.

John Rooke is chief operating officer at Bedfordshire Clinical Commissioning Group.