Varied local progress
In most places, changes in how commissioners and providers are working together are still an ambition and not quite a reality. This is reflected in the nature of this report, which provides a snapshot of current working and thinking among local leaders.
It is also worth remembering that systems are developing at different paces across the country, often managing distinct local challenges. Differential process is also seen across service areas. For example, considerable progress has been made in tertiary mental health services, where a lead provider has taken greater responsibility for developing pathways across regional networks of providers on behalf of NHS England, the responsible commissioner. Overall, it is clear that there is no single model that will work everywhere and systems need to be supported to work at different paces.
Some systems have moved on from talking about commissioning, and instead use a vocabulary of system and place to describe new and more collaborative ways of working. One CCG chief officer and ICS lead said: "We don’t even like talking about commissioning now. I always say on the patch: 'don’t use the c-word'. It doesn’t add anything. We’re a group of leaders and we should be together looking at quality and money and improvements. That’s what matters." Another CCG chief officer and ICS lead echoed this, noting that they no longer approach issues through the commissioner/provider relationship but look at the problem within that place, and then ask: "How can we take it forward? Who can contribute to the solution?" As a result, conversations are now much more transparent.
We don’t even like talking about commissioning now. I always say on the patch: ‘don’t use the c-word.’ It doesn’t add anything. We’re a group of leaders and we should be together looking at quality and money and improvements. That’s what matters.CCG and ICS leader
Other systems, partly in recognition of the fact that commissioning is the legally current term for a set of defined functions and activities, still use the term locally, while signalling an evolution of what it means and stands for.
It was clear that while contributors easily related to the concept of 'strategic commissioning', the language of 'tactical commissioning' (occasionally used in national policy documents to reference those activities which could be devolved from CCGs to a provider) did not resonate with anyone. In fact, contributors continually had to define those activities which might move to a provider, or providers, in the context of strategic commissioning.
The evolution of strategic commissioning
One thought leader drew on examples from other high-income countries with a purchaser and provider split. They thought a future strategic commissioner might focus on 'setting the system rules' such as specifying a 'care guarantee' with a prospective patient’s specific right to access and care standards, and regulating decisions, for example "so as not to squeeze out the voluntary sector and to control monopolistic behaviours". The commissioners’ overarching focus would then be on agreeing priorities, focusing on patient experience and outcomes, population health management, and governance of tax payers' money.
This vision may still be some way off, but some local areas, for example Surrey Heartlands, described how they had commissioned an external review to recommend how commissioning could evolve locally. This found that strategic commissioning functions and activities taking place either at ICS level or for the whole of Surrey Heartlands might include:
- business intelligence
- public health
- population health management
- digital strategies
- some procurement
- some clinical leadership development
- broad outcomes setting
- resource allocation
It was clear that while contributors easily related to the concept of 'strategic commissioning', the language of 'tactical commissioning' did not resonate with anyone.
Providers would then take over a number of the activities that CCGs currently carry out, for example pathway specification and redesign. Providers are arguably better placed than most commissioners to undertake such work and relaxing the service specifications that some commissioners set for providers would enable providers to innovate in the interest of outcomes over processes. Several commissioner and provider leaders noted that this would be welcome to reduce wasting valuable management time and resource on non-value adding contract discussions.
One CCG chief clinical officer and ICS lead described how integrated care partnerships may become "provider entities" that are likely to take on local planning of services, quality assurance and improvement, service redesign, and pathway redesign. Some commissioning activities are thus being brought together at a partnership level, with others carried out at place and neighbourhood levels, with a detailed commissioning framework setting out how this will work. More formalised and statutory commissioning functions such as the allocation of budgets and formal consultation may be carried out across a bigger geographical footprint at ICS level.
A number of clinical commissioners see strategic commissioning as the future destination for CCGs – primarily defined as the 'payor' function in a health and care system, clinically-led, operating at a scale larger than a current CCG footprint, and recognisably accountable to the local population. If strategic commissioning is 'the what', this would allow a lead provider, or a group of providers to lead on 'the how'.
We mustn’t lose the deeper understanding of local issues and the engagement with GPs locally that has been a real benefit of CCGs.Trust leader
Almost all contributors recognised a need for different commissioning footprints for different types of services. A number of contributors were clear that CCGs were undergoing a change process, whereby they were likely to become leaner and more strategic, and most thought this was appropriate for the current policy landscape and direction of travel. Several contributors specifically highlighted the importance of maintaining local autonomy and flexibility, and the need to balance that with the ‘bigger picture’ strategic approach that was recognised as necessary for effective population health management. Some suggested that provider partnerships as well as emerging forms of primary care provision (such as primary care homes, primary care networks and other models of primary care at scale) might be the new locus for truly locally grounded health and care partnership working.
One leader emphasised the importance of bottom-up leadership from GPs, stating: “We mustn’t lose the deeper understanding of local issues and the engagement with GPs locally that has been a real benefit of CCGs.” Beyond engagement, the importance of clinical leadership is also seen in the ability of clinical leaders across both commissioner and provider organisations to own and drive the local agenda and change needed, irrespective of the level that commissioning operates at.