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How will the Commissioning Outcomes Framework affect commissioners?

The NHS Commissioning Board's commitment to developing a national Commissioning Outcomes Framework (COF) became more of a reality earlier this month, when NICE released its first set of 44 outcome indicators.

The board is now close to deciding which indicators to select for its final COF for CCGs in 2013/14.

There are four main ways the COF will affect CCGs.

First, CCGs need a clear, overarching outcomes framework. At present, the first set of COF indicators have been released without a finalised framework within which to operate. In order to know the scope in which the indicators operate, CCGs will need to understand the expectations placed on them.

For example, if a CCG sees its current delivery against the COF indicators is in the 75th percentile against peer CCGs with similar needs and characteristics, what progress will it need to make? And will the degree of progress be the same when compared to a CCG peer in the 20th percentile?

Second, CCGs need a COF that brings some balance between national and local priorities, as it will form a critical element of the NHS Commissioning Board's relationship to CCGs.

The COF should, in the long term, enable CCGs to focus on clinical areas where their current level of ‘performance' against peer CCGs is weaker.

Every GP practice needs to have encouragement to achieve the COF, and CCGs where member practices don't engage with those targets will be less likely to achieve them.

Third, CCGs also need to have a clear commitment to outcomes over process measures.The health service and CCGs are very used to a target-driven culture, and in the future we need to avoid the worst excesses of what a focus on process-driven targets did.

For CCGs the board's selection of indicators for the COF will be critical on two levels – they must be well spread across disease areas to work well locally and they must be economic enough to avoid burdening CCGs with additional data collection.

Both these factors would avoid a ‘scattergun' approach to the use of clinical and managerial resources. Measuring success through outcomes will only be successful if CCGs work effectively in partnerships with the local authority, health and wellbeing boards and the Commissioning Board.

Finally, the COF should be supported by an incentive scheme, currently known as the quality premium.

There is considerable work still to do to clarify how closely the premium will be aligned with the COF indicators and how other incentives across the NHS system – such as CQUIN and the QOF – could be aligned locally.

The duty of CCGs is to commission the best possible healthcare for their population, so if savings are created in one area then the groups will have the power to reinvest them in effective providers.

However, achieving good results in one disease ‘domain', such as diabetes, might be linked to commissioning for other domains such as heart disease, so practice leads shouldn't expect to see direct funding gains based on their own commissioning decisions.

There is an urgent need to define the overarching framework for COF to prevent the indicators becoming a set of isolated measures.

Dr Charles Alessi is a GP in London, interim chair of the NHS Clinical Commissioners and chair of the NAPC