The childhood of the Health and Social Care Act has not been an easy one. And early adulthood looks to be equally difficult. The vision has always been a clinically led service based on outcomes and patient choice with high quality information, free of unnecessary bureaucracy. The vision is excellent and should be inspiring - yet there is uncertainty, scepticism and lack of enthusiasm in many places.
The reality is the Health Act and the Nicholson Challenge are here and despite the rhetoric, even a change of government is unlikely to alter the direction of travel.
I thought it would be useful to pick apart some of the current challenges CCGs face.
Changing mindsets
The problem with change is that it creates uncertainty and installing the necessary building blocks has been more difficult than anticipated.
I see many CCGs bogged down in the process of becoming a structure. The culture of PCGs and PCTs was all about process, structure, awaiting guidance, getting guidance and interpreting it and with few exceptions doing nothing new. I am concerned this may happen again. This Government wants to make things easier. The ethos is to encourage and permit innovation. Yet people are frightened to make big steps. When I ask new organisations how they are ‘flexing their muscles’ the response is usually to cite a referral management scheme which is quite small scale.
Many GPs are not used to commissioning on a larger scale. The current financial restraints mitigate against risk taking. The old management culture pervades and is likely to migrate to Commissioning Support Units. The Government does not want this to happen. In a sense CCGs have to ‘live in sin’ they have to start to do things before all the guidance is in place and even before they are a statutory body. They must take risks.
Competition
There is still an aversion to competition within the NHS yet we all intrinsically know that some competition makes people ‘up their game’ and creates innovative solutions.
I suspect people think that this Government is using competition to drive forward an underlying agenda of making the NHS an up-front fee based service which it most definitely is not. There is also a mindset that current NHS providers such as Foundation Trusts are always better and therefore the default choice for everything which they are clearly not. And many consider competition as causing fragmentation of a service. This is a valid point and good commissioning is about ensuring that this does not happen. Competition is a tool not an end in itself.
Provision
There are many clinicians who would love to get together to provide services and compete with others to provide the best. This is what doctors are good at and like to do. They are set to become the new providers but some issues currently hold them back.: Conflicts of interest are real , the Department of Health are cool about this and are certain they can find a solution. Problems with consultant contracts preventing them working for another employer is also problematic. New provider contract security and tenure and the difficulties of setting up as a new contractor are also bars to development. These are problems that will be solved so ‘Live in Sin’ and persuade your CCG to do so too.
Any Qualified Provider
And don’t overlook how Any Qualified Provider can make commissioning relatively easy. There are already over 30 different types of AQP service in England and over 500 services are approved or in the process of being so. It is a robust and reasonably easy way of commissioning services. AQP allows new providers to set up without major difficulty. It is a real opportunity for GPs who tend to think more about provision than commissioning in any case.
Dr Paul Charlson is a portfolio GP, RCGP Commissioning Champion and Strategic Medical Director One Medical Group
