Katherine Sheerin

Katherine graduated from Liverpool University in 1992 and joined the NHS general management training scheme.  Her final placement was working with GPs in Old Swan Health Centre and since then she has worked in a number of primary care and commissioning roles in Liverpool before becoming chief officer for NHS Liverpool CCG in 2012. 

 

Commissioning in the NHS faces hugely evident challenges, of which the biggest is money. There is simply not enough money in the health and social care system, so we’re facing difficult choices, which we’re making after difficult conversations with providers and system leaders.

The impact of funding constraints

There are financial shortages across the whole system. Dealing with them as best we can means aligning commissioners – across clinical commissioning groups (CCGs) with NHS England and local authorities – all working together to meet this challenge.

Liverpool CCG is responsible for half a million people, and we are the lead CCG for 7 providers, and 93 GP practices. But even as one of the largest CCGs, we don’t necessarily have the capacity to deal with the current challenges.

There is simply not enough money in the health and social care system, so we’re facing difficult choices, which we’re making after difficult conversations with providers and system leaders.

   

We’ve got great clinical leadership in Liverpool CCG, lots of it: we fund it properly. We had shadow running as three distinct patches, and that didn’t work well and we committed to using the economies of scale from having one CCG for the city to invest in clinical leadership and engagement across commissioning and provision. It’s all about that clinical leadership, which is probably as strong in Liverpool as anywhere else in the country.

Reforming CCG size and configuration

CCG size and configuration are issues. They’ll probably have to change, whether by formal mergers from the points of view of capacity and coherence. As providers coalesce, chains of providers develop for more integrated provision, the system can’t have a plethora of small commissioners trying to solve ever bigger problems.  However, we mustn’t lose local intelligence and engagement. It’s about what works. Regardless of shape, we need ways to keep local clinical engagement.

Of course there are also opportunities for CCGs, NHS England and local authorities to work together to effectively pool skills and capacity, and lead and engineer change on a bigger footprint for health and social care services. The sustainability and transformation partnerships (STPs) are definitely an opportunity if we get the footprint right. If the footprint becomes too big, you’ll lose the vital local understanding of how we can get to the end we need.

STPs

STPs can be a good vehicle for bringing people together to work out how to do all that (and how to influence at different levels). STPs vary in size, complexity and characteristics, so what works in one STP for primary and secondary care transformation won’t automatically be transferable to another.

Size and geography matter at this level too. Our STP population is 2.5 million, of whom 800,000 are in our north Mersey region, which centres around Liverpool and is very compact. So we can do more in north Mersey, more quickly. Changing care for the same population in a more spread-out geography will take much longer. The STP has added to the climate to allow change to happen, which might otherwise have been harder.

STPs vary in size, complexity and characteristics, so what works in one STP for primary and secondary care transformation won’t automatically be transferrable to another.

   

How devolution deals will affect commissioning has become more unclear since the EU referendum result. Some things have been devolved to our combined authority (Liverpool City Region), but not health and social care. It’s hard to see whether the devo trend will continue. [Former chancellor of the exchequer] George Osborne was very pro-devo.

I suppose that while the government is tied up in EU negotiations, it gives us time for thinking about how a form of devolution could work for us. We had wanted our STP footprint to match the combined authority footprint as if we were later going to devo, there would be no overlaps.  With clear messages that STP footprints may be given more autonomy we will probably need to re-visit our footprint to make sure it makes sense.

Blurring of the purchaser-provider split

New care models and new organisational forms do blur the purchaser-provider split. These discussions are part of our north Mersey local delivery system plan. All north Mersey provider and commissioner chief executives meet fortnightly with local authority representatives to ensure that we are making progress against all our aims, including reconfiguring hospital services, meeting more demand for services in the community and acting as one system.

Specialised trusts and services need to be part of the local level where possible, and only regional/national where necessary. Our hospital line is ‘local where practicable; central where necessary’.

   

In terms of specialised services, some commissioning will always stay very national and not involve us, but a lot of stuff is coming back locally. This makes sense as decisions on those services need to be considered alongside local services, and vice versa. So specialised trusts and services need to be part of the local level where possible, and only regional/national where necessary. Our hospital line is ‘local where practicable; central where necessary’.

The need to reform primary care

We went straight to co-commission primary care, and I think that should always have been CCGs’ task. There was a hiatus for two years while NHS England had responsibility and, as with specialised services, decisions need to be taken collectively. We sorted out a primary care wrap-around service (the Liverpool GP specification), which we commissioned as a locally enhanced service (LES) under the primary care trust, and continued with it as we transitioned into the CCG so we could keep developing and improving primary care. We have got to sort out primary care. If we do, the NHS could be sustainable; otherwise it’s very unlikely to be.

We’ve looked at outcomes-based commissioning. Our example is diabetes care: we sought the professionals’ advice, pooled budgets between hospital and community services, with the hospital as a lead provider.  Our contract now builds incentives for the hospital to do less complex activity by ensuring that patients are seen more proactively in the community. It has proved successful by getting the hospital and community providers together to work in more focused ways, and is already resulting in better outcomes for patients.

In terms of the purchaser-provider split and the future of commissioning in general, there will always need to be something – a needs assessment function, which sets outcomes and quality standards, pays providers and then monitors delivery, taking action where needed.

   

So, you absolutely need to build in outcomes to contracts wherever possible. Like our GP specification, which has resulted in 20,000 ‘missing’ people being included on disease registers. In primary care trust days, we had the national support team for health inequalities review our approach in Liverpool.  At that time they said that there were about 20,000 people missing from our disease registers.  Through the GP specification, we have identified many of them, and ensured that they are being managed appropriately.  This has resulted in reduced emergency admissions for these groups.

The future of the purchaser-provider split

In terms of the purchaser-provider split and the future of commissioning in general, there will always need to be something – a needs assessment function, which sets outcomes and quality standards, pays providers and then monitors delivery, taking action where needed. 

Some of what we do now may happen more in the provider system in future, for example service redesign, but we will still need strategic oversight and a way of holding the system to account.