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Past masters? What CCGs can learn from PCTs

Past masters? What CCGs can learn from PCTs

Insight: commissioning
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Elizabeth Wade
Head of Commissioning Policy and Membership, NHS Confederation

 

The rationale for and the likely benefits of the reorganisation of the NHS commissioning system have been debated at length over the past year. While opinion on this remains divided, one thing is generally agreed: if the new arrangements are to deliver different and better outcomes, simply changing the structure and architecture will not suffice. A different approach to the commissioning task itself is also required.

Elizabeth Wade
Head of Commissioning Policy and Membership, NHS Confederation

 

The rationale for and the likely benefits of the reorganisation of the NHS commissioning system have been debated at length over the past year. While opinion on this remains divided, one thing is generally agreed: if the new arrangements are to deliver different and better outcomes, simply changing the structure and architecture will not suffice. A different approach to the commissioning task itself is also required.

The reforms provide a real opportunity for new commissioners to make this happen, by securing genuine clinical leadership of their local health economies, engaging local authorities in new ways through Health and Wellbeing Boards, and using information and data more effectively to hold providers to account and drive improvements in quality and efficiency.

However, while the structure and model of commissioning may change quite significantly over the coming years, the emerging clinical commissioning groups (CCGs) will face the same challenges that their primary care trust (PCT) predecessors have been grappling with over the past decade. In fact, with the tightening of NHS resources and increasing pressure on the system as a result of demographic and technological changes, CCGs arguably face tougher long-term tests than any previous commissioners have dealt with before.

If CCGs are to be given the greatest chance of success in managing this resource challenge while achieving real improvements in the health of their populations, it is important to ensure that the experiences of PCTs, both positive and negative, are not forgotten. Understanding whether PCTs have been able to achieve what they were asked to deliver and why is crucial to understanding what new commissioners may need to change, discard or retain, and what the wider system needs to do to support them as they take over the reins.

Successes and failures
The constant change of structure and responsibilities of PCTs over the past 10 years has made it difficult to undertake any systematic or objective evaluation of their effectiveness as commissioners. Inevitably, there will have been individual cases of poor performance and failure within PCTs. We know that in some regards, for example in relation to reducing health inequalities, PCTs have collectively fallen short of their aspirations and objectives.

Overall, however, the available evidence suggests that PCTs have effectively played their part in delivering real and sustained improvements in the quality of health services, in the health status of local communities, and in the financial stability of the NHS. Indeed, looking back at their record of delivering the growing number of tasks and responsibilities they were charged with taking on over the years, many PCTs were going from strength to strength before their abolition was announced in 2010.

For example, while many PCTs struggled to achieve financial balance in their early years, this trend had dramatically turned around more recently, with their financial management generally strong and steadily improving by 2009/10. The short-lived World Class Commissioning programme only ran for two years, but also showed that many PCTs were making progress in improving their commissioning competence, with some already performing aspects of their role to standards approaching the best in the world.

As local system leaders, PCTs have overseen the implementation of a raft of national service improvement programmes that, among other things, have delivered reduced waiting times for inpatient, outpatient and A&E services, reductions in rates of hospital-acquired infections, and improvements in cancer survival rates and overall life expectancy, as well as countless local initiatives that have improved the quality, safety and outcomes of health and other public services.

CCGs will be operating in a different environment, in particular one where priorities will be more locally determined and resources more constrained. But the knowledge, experience and relationships that PCT staff and leaders have developed as they have undertaken this work will still be relevant to CCGs as they take over responsibility for this continuing modernisation and improvement of the NHS.

Leadership and support
One of the particular issues that PCTs (along with the payers or purchasers in most other healthcare systems) have faced is the perception, and often reality, that as commissioners they lack power and influence relative to the strength and dominance of health-service providers. That is, despite their best efforts and use of various incentives and sanctions to encourage providers to change, improve or redesign their services to better meet the needs of patients and provide better value to taxpayers, the interests of provider institutions and professionals tend to prevail.

The clinical leadership of the new commissioning organisations is intended to provide part of the solution to this dilemma, with clinical commissioners expected to bring more credibility and insight to the management of relationships with providers. However, while this will undoubtedly be an effective catalyst of change in many circumstances, it may not be sufficient to fundamentally alter commissioners’ ability to achieve the large-scale and systematic transformation of existing care models. Furthermore, other factors – such as the smaller size, and therefore reduced ‘purchasing power’ of many CCGs compared to PCTs – will present new challenges to commissioner-provider dynamics.

Whether or not individual PCTs were considered successful in influencing provider behaviour, there is likely to be much that clinical commissioners can learn from their experience and use to inform the design of new commissioning-support arrangements, the specification and use of data to monitor providers and hold them to account, and approaches to using choice, competition, co-operation and integration as levers for change.

There are also lessons here regarding the need for the wider system to support commissioners by ensuring that standard contracts, payment regimes and service specifications give commissioners effective incentives and sanctions, and that national leaders (political, managerial and professional) do not undermine commissioners’ (often unpopular) attempts to change local service models where these are in the interests of patients.

Memory transfer
With the Quality, Innovation, Productivity and Prevention (QIPP) challenge looming and full-scale reorganisation of the health service underway, CCGs have a difficult task ahead of them in ensuring that the progress made in recent years to improve the NHS continues.

It is generally accepted that if CCGs are to rise to this challenge the new system of commissioning must not simply replicate or recreate the existing one. But that is not to say that all the components of the current system are defunct or obsolete. The emerging leaders of CCGs recognise that there are many skilled managers and professional colleagues in PCTs who can help them seize the opportunities and avoid the pitfalls presented by the current reforms, and that a smooth transfer of corporate memory and capital will be essential to maintaining safety, quality and efficiency during the transition.

Achieving this depends on individuals engaging and investing in mature, and often difficult, dialogue during a period of unprecedented change and turmoil. While the real work to realise this can only be done by people working together at a local level, national policy makers and professional bodies can help to support them by promoting and modelling the type of relationships and behaviours on which an effective new system can be built.

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