Clinical commissioning groups

Abstract

When the Health and Social Care Act (2012) was passed, it was one of one of the most extensive NHS reforms ever seen in England. It gave rise to Clinical Commissioning Groups, which replaced Primary Care Trusts and larger strategic health authorities in April 2013. Commissioners identify the needs of the local population, set clinical priorities and purchase services on behalf of their community from a provider. Hospital trusts, community health groups, general practices, charities and private healthcare providers can ‘sell' services to the ‘buying' commissioner. This article will outline how services are commissioned in England, and explains how services are decommissioned when no longer required.

The GP curriculum and clinical commissioning groups

Professional module 2.02: Patient safety and quality of care requires GPs to understand that:

How and when to apply tools and metrics to improve the quality of care is a key skill that can and should be learnt during your training, as well as enhanced in lifelong learning

As a GP you are in a strong position to influence the care of your own patients, that of your practice population and that of the wider healthcare community

Professional module 2.03: The GP in the wider professional environment requires GPs to understand that:

The purpose of clinical leadership is to improve health outcomes and quality of care for your patients

Effective primary care requires the co-ordination and commitment of a multiprofessional team working in partnership with patients

Leading and managing improvement in healthcare systems is just as important as acting on behalf of the individual patient

Leadership is everyone’s responsibility, as a well led organisation is a safer place to work and receive care

As a GP you have a wider social responsibility to use healthcare resources economically and sustainably

Healthcare service structure

The Health and Social Care Act (2012) brought the term commissioning into everyday use for GPs. Box 1 provides some definitions for this and other common commissioning terms. The reforms saw the creation of NHS England, responsible for the commissioning side of the NHS in England. The responsibility for the health of citizens was removed from the Secretary of State for Health (a responsibility held since the creation of the NHS in 1948) and transferred to NHS England and Clinical Commissioning Groups (CCGs). The reforms sought to increase the power and ability of local healthcare teams (in particular GPs) to commission services the local population was considered to need. However, they were controversial, partly because they increased opportunities for private providers to engage with the NHS, and were opposed by a number of healthcare professional bodies including the RCGP (RCGP, 2011). Some responsibilities and staff were transferred to local government authorities, particularly those working in public health medicine. Sexual health, contraception and substance misuse services were also transferred to local authorities.

Box 1.

Definitions.

• Clinical Commissioning Group: A membership body of healthcare and lay members responsible for commissioning healthcare services on behalf of the local population

• Commissioning: The process of purchasing a service from a provider with defined outcomes, having assessed local needs

• Decommissioning: The ending of a contract or service that is no longer required

• Retendering: Offering a contract out to new bids, inviting competition to seek the most cost-effective provider available

In England, there are approximately 200 CCGs. These are clinically led with GPs, other healthcare professionals, lay members and a secondary care consultant on the governing body, and have a statutory responsibility within their local area to plan and commission healthcare services.

In Scotland, there are 14 regional NHS boards with responsibility for improving and protecting their population's health and delivering healthcare services. Additionally, seven special NHS boards (such as NHS Education for Scotland and Scottish Ambulance Service) and one public health body support the regional boards with specialist and national services (NHS Scotland, 2018).

In Wales, seven local health boards have a similar role in planning and delivering healthcare services for their areas. There is a unified public health organisation and seven community health councils that are statutory lay bodies representing the public interest in health services in line with the seven local health boards (NHS Wales, 2018).

Northern Ireland has six health and social care trusts, five of which operate in geographical locations, responsible for providing secondary, tertiary and social care in addition to primary care services. In addition, there is the Northern Ireland Ambulance Service operating across Northern Ireland. All trusts are expected to improve the health and social wellbeing of their populations and reduce health inequalities (Health and Social Care Northern Ireland, 2018).

Commissioning and specialist commissioning

Structure of CCGs

Each CCG has a membership that includes all local GP practices. They have an elected governing body comprising GPs, nurses, a secondary care consultant and lay members. The CCG is required to commission mental health services, urgent and emergency care, elective hospital services and community care. With an average population in each CCG of around a quarter of a million people, the population needs can be both varied and substantial (NHS Clinical Commissioners, 2018). CCGs are responsible for approximately two thirds of the NHS England Budget (£75.6 billion in 2018–19). Box 2 outlines an example of a CCG.

Box 2.

NHS Lincolnshire West CCG.

Lincolnshire West CCG is responsible for planning, commissioning, and monitoring GP, hospital, mental health and community health services on behalf of 240 000 people living in western Lincolnshire. The CCG membership is made up of 30 member GP practices, with doctors, nurses and other healthcare professionals leading it, supported by a team that helps manage performance contracts, finance, quality and communication. The CCG works with partners in public health, local and district councils, voluntary organisations and health and social care champion group Healthwatch Lincolnshire. The CCG is also responsible for commissioning hospice services, an ambulance service, NHS 111 and non-emergency patient transport, with a budget of over £300 000 000. The CCG works in close collaboration with other local CCGs, pooling resources such as the safeguarding team which is hosted by a neighbouring CCG, but works on behalf of four Lincolnshire CCGs. Lincolnshire West CCG encourages the public to join their local patient participation group at their GP practice, and also has a Patient Council as a reference group to contribute towards its strategic objectives (Lincolnshire West CCG, 2018).

Commissioning primary care services

Initially, NHS England was responsible for primary care services including general practice and dental services. Gradually, this responsibility has shifted from NHS England to CCGs. As of April 2018, 178 CCGs had taken full responsibility for commissioning primary care services locally (NHS England, 2018), one of the series of changes to primary care encouraged in the NHS five year forward view. CCGs are playing a key role in implementing changes from the GP forward view, such as extended access at evenings and weekends, and collaborative working of GPs bidding to provide services (Mills, Oyedotun, et al., 2018).

Commissioning secondary and tertiary care

CCGs are responsible for commissioning the majority of hospital and community healthcare services within their local area, deciding what services are required, and then ensuring that they are provided. Some services, clinics and treatments are either only required by a small number of patients, or the service is only provided in a limited number of hospitals or tertiary units. NHS England is responsible for commissioning these specialised services, and there are almost 150 of these services directly commissioned by NHS England. Four factors determine whether a service is specially commissioned: the number of individuals requiring a service, the cost of providing it, the number of people able to provide the service, and the financial implications for a CCG if they have to arrange the service themselves. Trial and pioneering treatments may also be commissioned in his way, such as bionic eye to restore sight and mitochondrial donation in in-vitro fertilisation to prevent passing on an inherited disease (NHS England, 2017). Box 3 gives examples of specially commissioned services.

Box 3.

Specially commissioned services.

• Chemotherapy

• Radiotherapy

• Kidney dialysis

• Hand transplants

• Osteo-odonto-keratoprosthesis

• Bionic eye

• Children's epilepsy surgery

Accountability

Although the Secretary of State for Health and Social Care no longer has responsibility for the health of the nation enshrined in statute, the Health and Social Care Act (2012) gave rise to NHS England and passed this responsibility to CCGs. CCGs work closely with, and are accountable to, NHS England. NHS England has to be convinced that a CCG is capable of improving health outcomes. NHS England, in turn, is accountable to the Secretary of State. Figure 1 provides a structure of commissioning responsibilities.

Figure 1.

Commissioning responsibilities.

There is also financial accountability, with the CCG having a duty to manage financial affairs well, use resources wisely and account for financial expenditure. CCGs have a financial officer to support this duty.

The Health and Social Care Act (2012) also created the economic regulator Monitor. Its purpose was to promote competition between providers and hold CCGs to account for procuring services. Monitor had enforcement powers for contracts, intervening if there was a breach of financial regulatory conditions. In 2016 Monitor was incorporated into NHS Improvement, the organisation that supports providers and holds them to account for delivering health services. NHS Improvement aims to work with NHS England in ensuring greater alignment between the financial levers for commissioners and providers (NHS, 2016).

GGCs are also accountable to their population. For example, lay members are involved in the governance of a CCG, governing body meetings are held in public, strategic plans published and there is engagement of CCGs with the local population to elicit views and priorities (NHS Commissioning Board, 2012). The Health and Social Care Act (2012) established an independent consumer champion for health and social care called Healthwatch, to champion the patient voice in helping shape services towards people's needs (Healthwatch, 2018). CCGs, as an NHS body, are required to consult with the Local Medical Committee (LMC) that represents GPs as individuals and GPs as providers of primary care services (Mills, Wordsworth, et al., 2018). Although LMCs have no formal CCG development role, they represent individual GPs in practices and are the membership of the CCG. Therefore, a healthy working relationship between a CCG and LMC is advantageous to the interests of both.

Although public health now lies within local authorities, there remains an ongoing need for collaboration with primary care. This is achieved through the establishment of health and wellbeing boards within the local authority, of which public health and CCGs are proactive members. Health and wellbeing boards have a statutory duty to bring both a local authority and CCG together to produce a joint strategic needs assessment and a strategy for the local population, aiming to integrate the NHS, public health and local government together in health and wellbeing (Kings Fund, 2016).

Decommissioning

As medical science and technology advances, bringing with it new treatments, many existing treatments become obsolete and cease to be cost-effective or best practice. Decommissioning is the process of withdrawing the funding for a particular service or intervention and ending a provider contract. It does not refer to redesigning a pathway, seeking bids from potential new providers (retendering) or revising a contract. In this sense, decommissioning is a natural part of the commissioning cycle, to improve efficiency and deliver services that better meet a population’s needs. Removing a service can be a particularly emotive for some within the population, and a decommissioning decision requires strong supporting evidence. For example, a consultation by one CCG to decommission a homeopathy service found very low levels of support within the local population for funding to continue. Clinical staff also supported the decision citing lack of evidence and ineffectiveness (Iacobucci, 2016). A decision to decommission is not permanent, and a decision may be taken in the future to recommission a service. If something has been decommissioned, it is also possible that an individual can obtain funding for it through the Individual Funding Request system if they can prove exceptionality. A case example of decommissioning is provided in Box 4.

Box 4.

Decommissioning example: NHS Scarborough and Ryedale CCG.

In 2017, NHS Scarborough and Ryedale CCG decommissioned gluten-free product prescribing to adults. The CCG recognised a prescription spend of around £60 000 was for gluten-free products. After an engagement exercise and seeking feedback from stakeholders, including charity and professional organisations, as well as patients and the public who would be most affected, a decision to stop prescriptions for gluten-free products was decided. The group had taken evidence and noted the increased availability in supermarkets of gluten-free products, as well as recognising they did not provide food prescriptions for other patient groups. Only a small number of gluten-free products could be prescribed (NHS Scarborough and Ryedale CCG, 2017).

Sustainability and Transformation Partnership

The way healthcare is organised and structured is constantly changing, just as healthcare constantly changes. Sustainability and Transformation Partnerships (STPs) were announced in 2015 and further plans developed in 2016. STPs will see 44 planned areas serving an average population of 1 200 000 that propose 5-year plans for NHS spending in England. It is possible STPs will supersede a number of functions currently performed by the CCGs. STPs seek to encourage plans that met the challenges of improving health and wellbeing, efficiency of services and improving quality of care. STPs also challenge healthcare leaders to identify the priorities for their local areas and how they will meet them, while achieving financial balance.

Although the Health and Social Care Act (2012) encouraged competition within healthcare, aiming to get competing providers to bid against each other for quality and cost, with STPs there has been a change in emphasis towards collaborating. It is envisaged that the NHS and social care systems will work more closely to provide more coordinated care services. There will also be greater pooling of resources and more working at scale. Increasingly, CCGs are working with neighbouring CCGs to share resources and functions to meet financial targets. Pressures and timescales facing those involved in developing local STPs have been immense, with plans changing and degrees of collaborative working inconsistent between different STPs. With different agencies all having essential and statutory functions to fulfil, collaborative working can easily fall in the list of immediate priorities (Kings Fund, 2017)

Long term plan

The NHS looks different from its inception in 1948, and will no doubt look different in the next decade. The NHS Long Term Plan aims to see additional funding for the NHS, keeping what is positive about the NHS and address the challenges that face it to future-proof patient care. This has seen the government announce funding that averages 3.4% a year over the next 5 years, sought consensus about what changes are needed from patients and professionals, and continue work from the ‘NHS Five-Year Forward View’ (NHS, 2019). Many commitments have been made to continue to integrate primary and community health services, reduce pressure on emergency and urgent care services, increase digitalisation of healthcare and commit the NHS to focus on population health (NHS, 2019).

Being a commissioner

Commissioning is an interesting and rewarding area in which to work, with challenging and complex dilemmas frequently arising that require strong leadership and business acumen. A good commissioner can enable quality care for many patients, using resources well and enabling other services to be provided. The NHS is changing, and the way we commission services is central to the future of the NHS and for delivery of the best outcomes for patients.

KEY POINTS

Health services are structured differently across the four nations of the UK

Commissioning seeks to purchase clinically and cost-effective care for a population

CCGs are responsible for a significant proportion of the NHS budget

CCGs involve members of local primary care services and the local population

Services are decommissioned when they cease to be clinically effective or cost-effective

Commissioning involves making challenging decisions on resource allocation

References

Health and Social Care Northern Ireland (2018) Health and social care trusts. Available at: http://online.hscni.net/hospitals/health-and-social-care-trusts/ (accessed 14 February 2019).

Healthwatch (2018) Our vision, purpose and strategy. Available at: www.healthwatch.co.uk/our-strategy (accessed 14 February 2019).

Iacobucci

(2016) CCG axes funding for homeopathy. BMJ: British Medical Journal (Online) 355: i5448 DOI: 10.1136/bmj.i5448.

Kings Fund (2016) Health and wellbeing boards explained. Available at: www.kingsfund.org.uk/publications/health-wellbeing-boards-explained (accessed 14 February 2019).

Kings Fund (2017) Sustainability and transformation plans (STPs) explained. Available at: www.kingsfund.org.uk/topics/integrated-care/sustainability-transformation-plans-explained#what-are-the-main-themes-in-stps (accessed 14 February 2019).

Lincolnshire West Clinical Commissioning Group. About us. Available at: www.lincolnshirewestccg.nhs.uk/about-us/ (accessed 14 February 2019).

Mills J, Oyedotun O, Ridout J, et al. (2018) The opportunities of economies of scale in primary care, InnovAiT. Epub ahead of print 15 March 2019. DOI: 10.1177/1755738018761501.

Mills

Wordsworth

Sharrock

(2018) Local medical committees. InnovAiT 11(11): 649–650. DOI: 10.1177/1755738018792291.

NHS (2016) How we work. Available at: https://improvement.nhs.uk/about-us/how-we-work/#providers (accessed 14 February 2019).

10.

NHS (2019) The NHS long term plan. Available at: www.longtermplan.nhs.uk/publication/nhs-long-term-plan (accessed 14 February 2019).

11.

NHS Clinical Commissioners (2018) About CCGs. Available at: www.nhscc.org/ccgs (accessed 13 March 2019).

12.

NHS Commissioning Board (2012) Clinical commissioning group governing body members: Role outlines, attributes and skills. Available at: www.england.nhs.uk/wp-content/uploads/2016/09/ccg-members-roles.pdf (accessed 14 February 2019).

13.

NHS Commissioning Board (2013) The functions of clinical commissioning group. Available at: www.england.nhs.uk/wp-content/uploads/2013/03/a-functions-ccgs.pdf (accessed 14 February 2019).

14.

NHS England (2017) Spotlight on specialised services. Available at: www.england.nhs.uk/wp-content/uploads/2017/09/spotlight-on-specialised-services.pdf (accessed 14 February 2019).

15.

NHS England (2018) About primary care co-commissioning. Available at: www.england.nhs.uk/commissioning/pc-co-comms/pc-comms (accessed 14 February 2019).

16.

NHS Scarborough and Ryedale CCG (2017) Decommissioning of gluten free prescriptions for adult patients in Scarborough and Ryedale. Available at: www.scarboroughryedaleccg.nhs.uk/news/post/decommissioning-of-gluten-free-prescriptions-for-adult-patients-in-scarborough-and-ryedale?UNLID=473016383 2018112752021 (accessed 14 February 2019).

17.

NHS Scotland (2018) Scotland's health on the web. Available at: www.scot.nhs.uk/organisations (accessed 14 February 2019).

18.

NHS Wales (2018) Health in Wales. Available at: www.wales.nhs.uk/nhswalesaboutus/structure (accessed 14 February 2019).

19.

RCGP (2011) Health and social care reform. Available at: www.rcgp.org.uk/policy/rcgp-policy-areas/health-and-social-care-reform.aspx (accessed 14 February 2019).

20.

RCGP. Clinical module 2.02: Patient safety and quality of care. Available at: www.rcgp.org.uk/training-exams/training/gp-curriculum-overview/online-curriculum/working-in-systems-of-care/2-02-patient-safety-and-quality-of-care.aspx (accessed 14 February 2019).

21.

RCGP. Clinical module 2.03: The GP in the wider professional environment. Available at: www.rcgp.org.uk/training-exams/training/gp-curriculum-overview/online-curriculum/knowing-yourself-and-relating-to-others/2-03-the-gp-in-the-wider-professional-environment.aspx (accessed 14 February 2019).