Developing a legacy

In April 2011, when both primary care trusts merged as one cluster, it made sense to have all clinical programmes in one place. The cancer network was approached by the PCT and asked to oversee the commissioning function and provide support to the emerging clinical commissioning group.

There is one CCG in Dorset and, following a series of discussions, 13 localities. These vary from a rural community to an urban conurbation and each is represented on the CCG board. The CCG has seven clinical programme boards, which are chaired by a GP, of which cancer and end of life care is one.

Dorset is one of the few CCGs that has chosen to employ local PCT staff, where possible, as its commissioning support.

It has one of the highest incidences of cancer per 100,000 population in England, with 4,500 new cases being diagnosed each year and about 6,500 people living with the disease. This is largely due to the larger numbers of elderly people in the county. It is also a high spending health economy and while there are excellent outcomes from cancer there is also opportunity to reprofile the programme budget.

Commissioning programme structure

The cancer and end of life care clinical commissioning programme (CCP) is chaired by a practising GP and supported by a team from the cancer network and PCT. This includes management, public health, information and finance. From a clinical perspective, senior clinicians represent oncology, nursing, surgery and solid tumour work.

Although patients are represented on the working groups there is not yet a representative at board level, as the programme wanted to ensure there was appropriate membership and wished to avoid tokenism.

Four subgroups were established to oversee the commissioning work programme and included early diagnosis of cancer, anti-cancer treatment, survivorship and end of life care.

These working groups are clinically led and managerially supported, whereas the strategy delivery group dealing in more operational issues was managerially led and clinically supported. The ethos is strong clinical leadership supported by professional managers.

Cancer networks have, by their nature, a wealth of experience and expertise to call upon, which ranges from patient representatives to tumour site groups and core staff with project management, service development, expert pharmaceutical advice, health economics and information analytical skills.

In any environment local knowledge and intelligence relating to the context of a situation plays a major part in designing services and addressing performance issues. Corporate memory is also integral to understanding the contextual issues relating to complex organisational culture and the rationale for change.

The core team from the cancer network was assigned to projects relating to either a commissioning function or one more appropriate to networks, and some straddled both work programmes.

The implementation of the national patient information system was a network project, while unbundling and reviewing a radiotherapy block contract was one aligned to the commissioning programme.

The cancer network board remained in place and addressed more operational health economy issues as it was felt the CCP needed time to embed itself before removing a strategic group prematurely.

The tumour site groups oversee policy and developments in their specialist areas and also undergo peer review. This valuable resource has been used to help the CCP prioritise developments.

When the CCP was first established, the GPs leading the programme met with the tumour site leads and senior clinicians to prioritise the work programme for Dorset. GPs now work with specialist clinical colleagues on the CCP board with a remit to bring their special expertise to represent patients’ interests rather than their profession’s or their employer’s. This principle is evolving as clinical commissioning develops.

Commissioning priorities is now a standing item on most of the tumour sites’ agendas and clinicians are asked to recommend treatments and review pathway issues that do not add value, as well as those new developments and technologies.

As an example of the way in which clinical commissioning is working, clinicians are teaming up to review the use of adjuvant chemotherapy where evidence suggests it does not add value to the patient pathway.

Locality integration

Dorset has 13 GP-led locality commissioning groups, which are responsible for local issues. Each locality is aligning a lead GP to link to the commissioning programmes. This means that cancer-related issues can be addressed via a local GP at practice level. There is tremendous potential to improve outcomes from diagnosing cancer earlier and in addressing the issues relating to people living with cancer by using this locality model linked to the CCP and cancer network.

One of the first things the cancer network did was to produce a report for each GP locality based on data from the GP practice profiles on the cancer commissioning toolkit. This included baseline data on screening, referral rates, emergency admissions and prevalence. The reports have enabled lead GPs to begin benchmarking practices locally and to lead any service improvement.

Lessons learned

In establishing a clinical commissioning structure several lessons have been learned:

• Involving patients in the commissioning process has required careful review and there is ongoing work around development of the patient panel to ensure they have a voice. The commissioning perspective was very different to that of several of the patients who have worked with the network over a long period of time and required considerable adjustment.
• Some clinicians “get” the commissioning principles and others less so. When we asked all the tumour site groups to prioritise developments not all saw this as their role, and so the network team had a supportive function in making sure any initiatives were highlighted so that patients would not be disadvantaged.
• Nursing and allied health professionals require more support in leading the commissioning agenda. In particular, there is a need to empower nurses to have a voice at the commissioning table and to understand the wider strategic agenda.
• The network core team experienced a steep learning curve in that this is clinically led commissioning that is managerially supported. This is particularly so for network roles with clinical titles when they fulfil operational positions in the core team.
• Robust project management governance is essential for reputation management and for clarity on decision making.
• Time set aside for clinical commissioning should be linked to job plans. Setting up and establishing groups and projects can often take a lot longer than planned simply by trying to get people in a meeting together.
• As CCG areas are larger, conference calls and video links are essential so that time and travel can be used as efficiently as possible.
• Cancer peer review plays a large part in the clinical network work programme each year. This is beginning to align well to the CCP for performance management of outliers and non-compliance. GP cancer leads are also beginning to take on the role of chairing local peer reviews for some tumour areas.
• The team found it helpful to meet with leading charities to outline how prioritisation works and how commissioning can work in partnership with other agencies.

Dorset is continuing to develop the clinical commissioning model aligned to the clinical network.

Although there is a national review of networks, with a likelihood of fewer and larger structures in future, the foundations of clinicians working together on commissioning issues has been set locally.

This means that whatever may happen to health service structures in future there is a legacy framework in place that will ensure that clinical commissioning in cancer supported by professional management can work effectively and in the best interests of the people of Dorset.

Rachael Rowe is lead manager of the Dorset Cancer Network and commissioning lead for cancer in the NHS Dorset, NHS Bournemouth and Poole PCT Cluster, rachael.rowe@nhs.net

Find out more

• Dorset Cancer Network