The NHS Commissioning Board has now confirmed that it has received applications from every aspirant clinical commissioning group (CCG), but this is just the beginning of the process. This transition from 151 PCTs to 211 CCGs is a huge logistical challenge, involving the transfer of public responsibility for £61bn of public expenditure, as well as hundreds of thousands of jobs. Those overseeing the transition have to juggle two not always compatible imperatives: maintaining financial control and creating a new form of commissioning culture which is distinct enough from what went before to justify £1.5bn in costs of the NHS reforms.
The resulting authorisation process involves CCGs having to submit 20 documents demonstrating how they meet over 100 criteria, as well as demonstrating that they are enjoying the confidence of key local stakeholders. For those who were excited (or concerned) that the reforms would simply involve turning novice GP commissioners loose, then the reality is somewhat different. Authorisation does not much look like liberation.
There are three phases of authorisation: pre-application, application and NHS Commissioning Board-led assessment. The Board will have to be assured that CCGs are able to commission the majority of healthcare safely, to discharge responsibly of the majority of the NHS budget and exercise their functions in relation to improving quality, reducing inequality and being efficient, and hence delivering better outcomes within their resources.
The very process has already changed the landscape of clinical commissioning. Since we published the path to GP commissioning the number of potential clinical commissioning groups has fallen to 211 – less than half the number forecasted by some commentators back in 2010. It is also clear that the priorities and focus of CCGs has evolved. In the path to GP commissioning we found the most common areas of focus relate largely to the integration of services, whether it be with social care, community services or improving the care pathway. Many consortia also opted to focus on governance issues relating to their establishment, rather than areas of commissioning which might have a direct impact on outcomes. This focus was perhaps to be expected given that a key task for pathfinders was to learn lessons about how GP-led commissioning can be most effective ahead of April 2013.
So, as the first wave of aspirant CCGs approaches the authorisation process, what has changed? Wave 1 will be particularly significant as it encompasses many of the most enthusiastic proponents of clinical commissioning. It will set the tone for what is to follow.
Through CommIT, our commissioning intelligence tracker, we have analysed the priorities which Wave 1 applicants are electing to focus on. Our analysis shows that reducing unplanned admissions and A&E visits, improving dementia services, and diagnosis and treatment of mental health are the dominant priorities.
For those concerned with how CCGs will (or won’t) relate to local communities, this news will be heartening. The focus on clinical issues rather than administrative processes is likely to resonate more with local people. It is also notable that unplanned admissions, dementia and mental health have all been areas of health with have received a significant national political focus. Perhaps the priorities of local and the centre are not that different after all.
Some aspirant CCGs have changed their focus significantly. NHS East Riding of Yorkshire CCG has set specific local outcome targets for the current financial year 2012/13. Success will be demonstrated for this CCG if 50 more patients die in a location of their choosing; 600 more people are diagnosed early with dementia; 580 people living with a long-term condition are supported to avoid a non-elective admission; and 3,000 more personal care plans are put in place for people with long-term conditions and multiple care needs. It is easy to see how these measurable priorities could form the focus of meaningful dialogue with and accountability to the local population. Contrast this approach with the priority of the East Riding Transition group in 2011, which wanted to focus on ‘contracting expertise’ as its main goal.
There are some other good examples of local engagement. Cumbria CCG is performing its own listening exercise on commissioning, complete with a roadshow and dedicated website and Bassetlaw CCG is undertaking a public engagement survey on priorities, including seeking public views on the relative priority which should be given to all NHS Outcomes Framework indicators.
However there remains a good deal of variation in the priorities of aspirant CCGs, as well as the extent to which they are expressing them in terms which enable meaningful accountability and engagement. Only 13 of the 35 first wave of CCGs have a defined plan of the priorities with reference to specific disease areas. Nine groups have no public facing information on what their strategic plan is. 14 per cent have vague mission statements and objectives that are yet to be developed – goals to ‘promote health and wellbeing’ and ‘use our resources wisely’ have been offered, with little or no further explanation. It is clear that some CCGs have some way to go before they are behaving like accountable and accessible public organisations – over a quarter of the first wave do not even have a website, and many of those that do, bury their priorities in dense committee minutes, immense commissioning plans or dark corners of existing PCT websites.
The variation in the progress of CCGs shows that the commitment to public accountability in clinical commissioning remains mixed. As with PCTs, there are some examples which deserve to be applauded and emulated. There are others which offer less hope. Wave 1 of the aspirant CCGs may well be the trailblazers. Which of this group prove to be the trendsetters will go a long way to determining the nature, culture and success of clinical commissioning.