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England’s clinical commissioning landscape

Who are the real masters in the new NHS?

In April 2013 the healthcare landscape in England was fundamentally restructured with the creation of more than 200 GP-led Clinical Commissioning Groups (CCGs) and between them they are in charge of managing two-thirds of the NHS budget.

Since then further new structures, organisations and acronyms have been created and renamed as the government sought to put clinical commissioning at the heart of its healthcare reform programme.

It is the biggest reorganisation of healthcare services in England since the NHS was created, and it's not over yet.

The 211 CCGs are monitored by, and co-commission services with, NHS England (formerly known as the NHS Commissioning Board). They are aided by commissioning support units (CSUs), which are responsible for logistics, service redesign, market management, healthcare procurement, contract negotiation and monitoring, information analysis and risk stratification. These are subsidised by the NHS, but are expected to become profit-making businesses or public/private joint ventures by 2016.

Many CCGs have alliances and share staff and resources to reduce costs and the trend seems to be towards consolidation of a model that is still too fragmented. Gateshead, Newcastle North and East and Newcastle West CCGs have initiated an authorisation process with NHS England to merge into a single CCG, serving a population of around 500,000.

Half of GPs said being part of a CCG had altered their prescribing patterns

With such widespread changes teething issues were inevitable. One such problem for clinical commissioning has been defining how providers operate, how they are evaluated and implementing checks and balances for the relationship between commissioners and providers. Clearly, when clinicians are both commissioners and providers, conflicts of interests may arise.

There have also been controversies on attempts by some CCGs to introduce outcomes-based commissioning, which has been rattling traditional providers. In Oxfordshire, the Oxford Health Foundation Trust and Oxford University Hospitals Trust objected to such plans on the basis that they bring new financial and clinical risks and affect the local health workforce. For some, this means that providers are the real masters in the new NHS, as they have more data and a firmer grasp of competition law.

Funding issues and private providers
The upheaval hasn't just hit structures and working arrangements - budgets have been affected too. Prior to a new NHS England budget formula being put in place some CCGs lost at least £10m of the funds originally allocated to them for 2013-2014, due to having been wrongly given money earmarked for NHS England and specialised services.

NHS England's new formula to calculate budget allocation for CCGs is aimed at reflecting more accurately population needs and target inequalities. It should see budgets rise in line with inflation and protect them from public sector austerity cuts. The new formula takes into account inflation, growing and ageing populations and underfunded areas, through a specific deprivation measure.

Nevertheless, a King's Fund survey suggests that one in eight CCGs will be in deficit this April with most CCG finance leads saying they were 'very pessimistic' about the next financial year. Adding to this, GP leaders claim that extra funds are desperately needed and that the pressure is mounting to reduce prescription costs. Maureen Baker, chair of the Royal College of General Practitioners (RCGP), has urged all CCGs in England to “use their funding powers wisely” in order to pull back the decline in funds which, it is claimed, is affecting patient care. The RCGP is suggesting that CCGs can get extra cash from other available sources of healthcare funding, such as the Better Care Fund, the £5 per patient allocation to enable the provision of 'accountable GPs' to vulnerable over-75 year olds and the Challenge Fund, created to stimulate new ways of providing primary care services, for which practices are being invited to bid to become pilot sites.

NHS England has also started to advertise for companies to compete to advise CCGs on patient care reforms, finances, drug purchasing, negotiating hospital contracts, handling NHS patient care data and other consultancy work in conjunction with CSUs.

On this point Bob Ricketts, director of commissioning support strategy at NHS England, told the Financial Times that the primary aim was to “create a competitive market” in the buying of healthcare services. This is a highly sensitive political issue that is becoming a reality with huge opportunities for private investors, many of whom are already running services.

Bidders have 11 weeks to draft their applications, with NHS England due to announce which organisations have passed the first stage in July. Successful providers will be disclosed at the beginning of 2015. But critics say that the market for healthcare procurement will be expensive, fragment services further and weaken clinical commissioning groups, who are already dependent on providers' contractual experience.

Challenges and opportunities for pharma
Working alongside industry body the ABPI, NHS England has said it will provide greater transparency for, and engagement with, the pharma sector, and develop partnerships to share information, analysis and insight to improve care.

One key benefit that NHS England Clinical Reference Groups (CRGs) can expect from a partnership with pharma is the development of processes to provide medical information on the use of unlicensed medicines, subject to a documented request from a CRG, when there is clinical need in individual patients and no suitable licensed alternative, which had proved difficult before. In turn pharma may benefit from greater collaboration on the development of drug research, care pathways and effective ways of administering treatments when working with CRGs.

But there are serious challenges ahead. The landscape is constantly evolving and the goalposts are shifting. Cost-cutting is a priority with more than two thirds of GPs reporting a rising pressure on prescribing budgets.

Some CCGs have reported significant financial pressures on prescribing budgets during the current financial year and many have continued to run prescribing incentive schemes to make the most cost-effective use of medicines.

Looking to the influence of CCGs in their first year, a joint King's Fund and Nuffield Trust survey found that more than half of GPs have said that being a member of a CCG had altered their referral or prescribing patterns.

The survey found that almost 60 per cent of the 207 respondents in six chosen CCGs had altered prescribing patterns, almost 75 per cent had changed their referral pathways and just over 50 per cent had changed their referral volumes.

Levels of GP involvement in CCGs vary and surveys show that the reform has not been embraced, is not clearly understood or is open to many interpretations. The PCT model was in place for more than a decade, so it will take time to fully assess the impact of clinical commissioning.