Debate & Analysis Primary care co-commissioning: challenges faced by clinical commissioning groups in England

INTRODUCTION The English Health and Social Care Act “Co-commissioning is intended to support the 2012 gave GP-led clinical commissioning groups (CCGs) responsibility for development of integrated out-of-hospital services commissioning the majority of healthcare based around local needs.” services for their registered population. However, responsibility for commissioning primary care services was given to a new national body, NHS England (NHSE),1 to Commissioning Committee (PCCC) as a requirements for CCG mergers have also 1 avoid conflicts of interest and because of sub-committee of their governing body been updated to include the need to align a perceived need for a standardised and (GB). Unlike other sub-committees, which CCG ‘footprints’ to support STP delivery.9 In 2 consistent approach to commissioning. It make recommendations to the GB,3 PCCCs practice, STPs have been criticised for their soon became apparent that NHSE was have decision-making authority. To ensure lack of GP involvement. struggling to move beyond a transactional transparency and avoid conflicts of interest approach to commissioning, focused on (CoIs), PCCCs are chaired by a lay member DISCUSSION payments and contract management. and have a lay/executive majority.4 What are the challenges associated with When Simon Stevens took over as the primary care co-commissioning in the Chief Executive of NHSE (April 2014), he WHAT DOES IT INTEND TO ACHIEVE? context of these changes? One of the advocated transferring responsibility for The NHS Five Year Forward View (FYFV) biggest concerns underpinning the original commissioning primary care services called for ‘new care models’ (NCMs) that decision to give responsibility for primary from NHSE to CCGs. Two years on, envisage local commissioners and providers care commissioning to NHSE was CoIs.1 how have CCGs responded to their new working together to break down the However, in practice the need for policy responsibilities and what challenges do boundaries between primary, community, ‘workarounds’ to solve the fragmentation they face? and secondary care.5 Co-commissioning introduced into the system by the Health WHAT IS PRIMARY CARE is seen as a ‘key enabler’ to drive the and Social Care Act 2012 outweighed CO-COMMISSIONING? development of NCMs. It is intended that this concern. When primary care CCGs will take a more integrated approach co-commissioning was introduced, it was Co-commissioning is intended to support to commissioning,4 which will enable a shift argued that robust governance processes the development of integrated out-of- of resources between sectors and facilitate and decision-making transparency would hospital services based around local needs. the development of integrated organisations alleviate CoIs.4 Two years on, concern The scope of co-commissioning in 2015– delivering NCMs. This is seen as a step over CoIs remains.10 There is little publicly 2016 covers only general practice services, towards ‘place-based commissioning’,6 available information on CCGs’ arrangement including: managing practice contracts; commissioning enhanced services and which in turn will support planning by place to manage conflicts, and NHSE has little data local incentives; establishing new GP for local populations. This will allow the about how effectively they are doing this, practices; and approving practice mergers. local development of Sustainability and relying on an exception-based assurance It excludes individual GP performance Transformation Partnerships (STPs). process and on Monitor as the system 11 management. STPs were first introduced in the 2016– regulator. This raises questions about both 7 There are three possible levels of 2017 NHS planning guidance, being likened transparency and local accountability. There responsibility: greater involvement — to a ‘route map’ representing different ways is considerable variability in the processes CCGs have ‘influence’ in shaping primary of working, bringing together health and care used by CCGs to manage CoIs, ranging from care; joint commissioning — CCGs share commissioners and providers. Although the minute taking and updating declarations responsibility with NHSE regional teams; 44 STP ‘footprints’, with leaders agreed by of interest to no clearly defined process 12 and delegated authority — CCGs lead NHSE, are not statutory bodies and do not to manage breaches. However, with primary care co-commissioning. The policy replace existing local bodies or change most CCGs claiming that their concerns intention is for all CCGs to ultimately take accountabilities, the importance of STPs centre on the perception rather than actual on delegated responsibility. However, in as a vehicle for change is reflected in conflicts,6 having guidance that attempts April 2015 a large proportion (87 of 209 this year’s operational guidance,8 in which to cover every eventuality risks making the CCGs) opted for joint commissioning, due they form a key element. The criteria and process a tickboxing exercise. to uncertainty over what co-commissioning would involve. One year on (April 2016), 115 of 209 CCGs (55%) have delegated responsibility, 68 (32.5%) joint “Clinical leadership is already somewhat eroded by commissioning, and 26 (12%) greater the fact that GP members do not form a majority on involvement. Under delegated responsibility, decision-making PCCCs.” CCGs must set up a Primary Care

British Journal of General Practice, January 2018 37 ADDRESS FOR CORRESPONDENCE Imelda McDermott “Performance managing their own members is University of Manchester, Health Policy, Politics and challenging for CCGs, who have tried to make this Organisation Group (HiPPO), Centre for Primary Care, 6th Floor, Williamson Building, Manchester more palatable by shifting the discourse away from M13 9PL, UK. ‘performance management’ to … ‘peer support’.” E-mail: [email protected]

organisations at a time of considerable turmoil and change. We are also grateful to Dr Lynsey Warwick- Second, guidance suggests that CCGs opportunities this affords them, but it is Giles, Dr Donna Bramwell, and Dr Valerie Moran, will be responsible for liaising with the Care as yet too early to tell how far this will who are involved with the project. Quality Commission (CQC) about issues be achieved.6 In terms of supporting the relating to practice performance, but will development of new ways to deliver care, DOI: https://doi.org/10.3399/bjgp17X694325 not be responsible for issues relating to our ongoing research suggests that the individual GP performance, which remains ability to vary local contracts for enhanced with NHSE. In practice, these two things primary care provision has supported the may not be easy to separate. For example, incentivisation of practices to work together CQC inspections may flag up problems ‘at scale’. The hope is that practices with individual GPs. CCGs are constituted will eventually move towards different as ‘membership organisations’, with organisational forms that could take on every practice required to be a member. new contracts arising out of the FYFV, such Performance managing their own members as multispecialty community providers is challenging for CCGs, who have tried (MCP). STPs may require changes to the REFERENCES to make this more palatable by shifting way general practice is delivered, and buy- 1. Department of Health. Equity and excellence: the discourse away from 'performance in will be difficult to achieve if GPs have not liberating the NHS. [White paper]. London: The Stationery Office, 2010. management' to 'peer-learning' or 'peer been included in the discussions. support'. As these changes unfold, CCGs as 2. NHS Commissioning Board. Securing excellence in commissioning primary care. Third, as GP federations and super- membership organisations need to ensure NHS England, 2012. partnerships become more common it that they bring their membership with them 3. McDermott I, Checkland K, Coleman A, et would make sense for GPs who have an to maintain the clinical voice and local al. Engaging GPs in commissioning: realist appetite for lead roles to focus their efforts understanding. evaluation of the early experiences of clinical commissioning groups in the English NHS. J as providers of services rather than as Health Serv Res Policy 2016; 22(1): 4–11. commissioners. This may have significant Imelda McDermott, 4. NHS England. Next steps towards primary implications for the sustainability of CCGs as Research Fellow, Health Policy, Politics and Organisation Research Group (HiPPO), Centre for care co-commissioning. London: NHS clinically-led commissioning organisations, Primary Care, University of Manchester, Manchester. England, 2014. as they may struggle to fill GB places. 5. NHS England. Five year forward view. NHS England, 2014. Clinical leadership is already somewhat Kath Checkland, eroded by the fact that GP members do Professor of Health Policy and Primary Care, Health 6. McDermott I, Checkland K, Warwick-Giles not form a majority on decision-making Policy, Politics and Organisation Research Group L, Coleman A. Understanding primary care co-commissioning: uptake, scope of PCCCs. This means that significant (HiPPO), Centre for Primary Care, University of Manchester, Manchester. activity and process of change. Manchester: decisions affecting local practices may be PRUComm, 2016. made that GBs cannot overturn. 7. NHS England. Delivering the forward view: Last, with no additional financial resource Anna Coleman, NHS planning guidance 2016/17–2020/21. Senior Research Fellow, Health Policy, Politics and NHS England, 2016. and a loss of managerial expertise since Organisation Research Group (HiPPO), Centre for 8. NHS England, NHS Improvement. NHS PCTs were abolished, CCGs are grappling Primary Care, University of Manchester, Manchester. operational planning and contracting with difficult organisational and structural guidance 2017–19. NHS England, 2016. issues around commissioning primary Provenance 9. NHS England. Procedures for clinical 6 care. The previous transactional approach Freely submitted; externally peer reviewed. commissioning groups to apply for taken by NHSE left CCGs having to deal constitution change, merger or dissolution. NHS England, 2016. with considerable legacy issues such as Competing interests 10. Robertson R, Holder H, Bennett L, et al. getting hold of and understanding existing The study was funded by the Department of Primary care co-commissioning: a survey of contracts. Health via its Policy Research Programme. The members’ views of their CCG and its role in study formed part of the programme of the primary care. London: King’s Fund, Nuffield CONCLUSION Policy Research Unit in Commissioning and the Trust, 2015. Healthcare System. The views expressed here are 11. National Audit Office. Managing conflicts The policy intention underlying the those of the researchers and do not reflect the of interest in NHS clinical commissioning transfer of responsibility for primary care position of the Department of Health. groups. London: NAO, 2015. commissioning to CCGs was to allow more 12. NHS England. Co-commissioning conflicts integrated commissioning, with the ability Acknowledgements of interest audit: summary report. NHS to shift resources around the system. We are grateful to our participants, who were England, 2016. CCGs are clearly enthusiastic about the very generous in allowing us access to their

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