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NAPC Roundtable: Where will power lie in the new commissioning era?

Leading commissioners sat down last week to discuss whether CCGs are being given the powers and independence they need to make a success of the NHS reforms. Here are the highlights froma lively debate.

Richard Hoey (RH) One of the key issues of the moment is commissioning support. Critics warn draft Government guidelines appear to potentially privatise managerial support in the NHS, but many proponents were of the view that – in the next two years at least – it may severely restrict choice of commissioning support for CCGs. What do you think?

Dr Charles Alessi (CA) The commissioning support organisations (CSOs) that have been designed are large and also only give one option around what they offer. A different approach, for example, would be to obtain support around contracting from the local authority. Commissioners do not have a real choice. What we require is a mixed offering.

Cllr Derek Osbourne (DO) There is an awful lot of effort going in to develop CSOs – but we don't know what shape they will be, what governance or budgets they will have, who will be in them, or if they will be financially viable. There is a danger that the guidance will push people into a non-workable organisation when much of the non-specialist support can be provided by the local authority or can be seconded easily and cheaply from existing NHS units.

Dr Joanne Medhurst (JMe) The issue is about how you match what is needed to the organisation that does it for you. We need flexibility to be able to buy from the best provider. CCGs have to think about the management experience that already exists. The market may develop, but I think that's going to need some encouragement and some support. The other issue is if CSOs become too big they suck the resource out of the CCGs.

Dr Phil Moore (PM) We've had experience of working with a larger organisation where some of the things that we have said we want have been turned over without reference to us and implemented with providers, and it's been a surprise to us.

What we're now saying locally is we want a very small core and we want lots of other offerings so we can buy in those bits as we need to. The problem we're having is that currently the commissioning support organisation is saying, with direction from above, that what they require is about 60% of our management money – which doesn't leave us a lot to do things locally. That's completely upside down. Mental health is an obvious area where using local experience, skills and enthusiasm is key. Psychology services, counselling, substance misuse and community mental health services are all provided locally and should be done at the local level. You do not need a commissioning support organisation by and large to do that kind of thing.

For things like inpatient care and specialist services, these clearly need to be done across a wider area – that doesn't necessarily need a CSO, but for us to work with other CCGs. There seems to be a presumption from above that unless we have a CSO we're not going to work together. I think history shows us that's not true.

Dr Johnny Marshall (JMa) How some CSOs are developing in terms of their offering is by offering some flexibility and different levels of support you might be able to secure. But many that I hear of have come with one single offering that says we can offer you all this support and it will cost you £10, £12, £14, £16 per head without that flexibility, and so it doesn't encourage CCGs to look at other options for commissioning support. We've got some difficult challenges to face and we need the very best support, so I think it's really important emerging CSOs really understand what their function will be and are providing the right offerings.

RH The Department of Health's commissioning support document talks about local authorities as being a potential source of support in the future. How might this work?

CA Surely the future is co-commissioning? In London we probably have the best stroke services for a capital city, but the moment you leave hospital the services are as variable as they always have been.

It is obvious we need to co-commission to develop the whole of that pathway, and this is achievable as long as there is mutual respect and understanding of accountabilities and responsibilities.

JMe Working with the local authorities and commissioning together as you move care from the acute system into the community is absolutely essential. We need to be honest and transparent about where the money is being moved around the system, the cost to the local authority and the cost to health. We also need flexibility around the budgetary system. But I don't think we should underestimate how difficult that culture change can be.

JMa We need innovative solutions for a shared problem or there is a danger of shunting costs from one organisation to another. Councillors and GPs are well placed in their communities to understand each other's needs and how we might work differently. But it does require a relationship as equals around a common agenda for it to be really successful.

DO The current legislative process has rather slowed down the process of integration. So before the health bill, our PCT voted to abolish itself and to merge most of its structures to the local authorities and so were looking to go down a joint commissioning route. We were all set to do this and we were told we had to slow down because we might develop a model that worked, but didn't look like the one the Government wanted to develop.

PM We've invested probably eight years' worth of joint meetings with the local authorities. There has emerged a shared agenda for the future, a concept of how we should be organising services, both from the social care side and the health side. When you put things together in proper joint commissioning, you end up making decisions together that ask: ‘What is best for us as a community?'

RH There's been plenty of criticism of the way that PbR works in rewarding the generation of demand in secondary care. How big a challenge do you think this is for CCGs, and how should they address it?

CA Unless we manage this process better and align the incentives, we're not going to succeed. We are starting to move to a situation where we're measuring spells, improvements within a spell, within a period of time, irrespective of how many times you're seen. I'm encouraged by the fact that some of our hospitals are starting to understand this.

PM We've come across up-coding by hospitals. I'm not convinced this is deliberate all the time. I don't think hospitals by and large have got the capacity or even the will to deliberately up-code things. However, the fact that it happens, for whatever reason, is a problem because it means we're paying over the odds. If we allow that to continue without challenge, then we're guilty of not managing the money effectively. We need to divert such money into preventative care. Unless we address the real preventative issues we will not be able to survive as a health service.

JMe I would make it about quality, because actually the coding mess is about money – but it also tells you what your service is, what you're buying and how your service might need to change. You do need accurate data so then all of the tension and that adversarial element falls away.

JMa Until now, commissioning has really commissioned activity rather than outcomes. PbR is all about activity and so we're in this transactional way of doing business, so you up-code, you try and get your codes correct and actually I think more (acute trusts) are investing in taking more coders on. We have a finite resource to invest within the population so we need to move to activity that delivers outcomes. If I were to walk down the street, pick people at random and ask if they would prefer not to have a stroke or have the best possible hospital care when they had a stroke, nine out of 10 would say the former. So how about the acute trust, as well as providing high-quality services for stroke sufferers, also along with everyone else has an accountability to reduce the number of strokes?

DO The fundamental difference between contracting and commissioning is that commissioning is not about processing a set of numbers, it is about the life expectancy of the person coming out at the other end – or what support they get in the community.

I think local authorities have been doing commissioning based on qualitative outcomes rather better.

RH How appropriate do you think the £25 management allowance is?

JMa If you're setting up a system where the secretary of state has a duty to promote autonomy and the NHS Commissioning Board has a duty to promote autonomy and then you start to constrain how statutory bodies can operate, you might come up with some of the wrong limitations and inhibit success within organisations. I suspect the first CCG that delivers on all of its health outcomes, all of its public engagement and comes in under its total budget but that has spent more than £25 on management might not get quite such a hard ride as we imagine.

CA The £25 a head misses the point – that autonomous organisations should be making decisions in terms of resource. It presupposes that there's only one way of doing things. A judgment has been made that it will cost £25, but actually that's the way we used to do things – not the way we're going to do things.

PM I've seen this cycle where suddenly you get contraction and people are made redundant, and then it expands again. This is just one more of those cycles. It's actually more important that we deliver health for our populations, but for the first year or two it will be a means of proving we're able to function within the constraints provided.

JMe We do have a paradox in this £25, because to live within it you're going to have very little ambition, very little scope for change. It'll be very good at keeping the status quo, but we've got £20bn to save in the NHS in the next four years. We need to have some flexibility to help redesign a very difficult system.

DO This is just somebody licking their finger and sticking it in the air, isn't it?

RH What approach should CCGs take to make sure they don't replicate the mistakes of PCTs, but do actually invest to produce genuinely radical change to the health system?

CA We need to have a longer-term view, and a year annual (budget) cycle is not helpful for that. I think it's inevitable (to move to longer-term funding cycles) if we are going to achieve what we need to achieve. We have a real opportunity around public health. In changing the relationship between the population, the patient and the clinician from one which is paternalistic to one that is engaged is the future. It's far more likely that this is going to happen in this environment.

JMe When there is really good innovation, where something works, how do we connect the system together? We do need to work together to drive this change. There is a need to make significant savings, but we just seem stuck in debate about the how. Actually, we need to get on with doing it.

PM One thing we can learn from the past is that many projects have started and another directive has come down from on high, and everybody's been diverted. We've got to handle the ongoing directives that are going to come from the Government in a way that we don't get diverted from the real job of making the changes in the system that are going to deliver healthcare for our population.

JMa The challenges we face around long-term conditions, an ageing population and dementia require new innovative solutions. You have to create the right environment, the right support – outlining the outcomes you want and then supporting and enabling the clinicians, the public, the other professionals in social care to work together. Unless you do that we will have learned very little from the past.

DO Somebody has got to realise that the best way to create innovation, change and difference, and a learning environment is

to say: ‘I'm not going to give you any guidance on that, because I don't know the answer. I do not know the answer so how can I give you guidance?' They're scared that this change will go badly wrong… so therefore they're not allowing innovation. That guarantees it will go badly wrong if they're not careful.

RH Charles, I'll let you have the last word. Do you share the concern over the potential powers of the NHS Commissioning Board and how it will use them?

CA We have to remain optimistic and we have to continue to put pressure on the commissioning board to reform in a way that allows the CCGs and the local authorities to thrive. If the NHS Commissioning Board ends up being a prescriptive, controlling organisation, I think we'll fail. If, on the other hand, it promotes the autonomy of CCGs – I think there's every chance we will succeed.