Policy context
Despite the lack of legislative change since the 2012 Health and Social Care Act, the commissioning landscape is evolving at pace and increasing emphasis is being placed on collaboration over competition by both national and local NHS leaders. Within STPs and ICSs, clinical commissioners and providers are reflecting this as they look to work in different, more collaborative ways to deliver the best outcomes for their local populations, independent of organisational boundaries.
CCGs are coming together across larger geographical footprints. Arrangements include formal mergers, shared appointments and management teams, establishing committees in common, or commissioning on another CCG’s behalf. CCGs are also increasingly working in close collaboration with their local authority commissioners, sometimes merging their respective commissioning teams.
NHS England has been considering how to ensure it works closely with CCGs and networks of providers to devolve responsibilities for developing and delivering specialised services and to adopt a more 'place-based' approach. This work is proving successful in pilots which devolve responsibilities for specialised mental health services to networks of providers across a larger geography, for example.
Providers are likewise continuing to develop new ways of working, adopting a variety of integrated care models. Some are looking to become integrated care providers or enter into integrated care partnerships, either through alliance or prime provider arrangements, while others are looking at horizontal forms of integration, for example through group models.
The commissioning landscape is evolving at pace and increasing emphasis is being placed on collaboration over competition by both national and local NHS leaders.
The relationship between clinical commissioners and providers therefore seems on the brink of significant change, with commissioners taking a more high-level, strategic approach, and providers taking on or supporting some more tactical or transactional aspects of the activities previously undertaken by CCGs. With this change, clinical commissioners could focus on working to assess population health needs and forecast demand, planning the nature, range and quality of future services and defining and contracting for outcomes. They would act as the 'stewards' of the system, but critically would need to have a strong relationship with providers and a real sense of ownership about what needs to happen across a system. Individual providers, or an alliance of providers, could in turn take over or support some functions that they would arguably be better placed to execute at a more local level. This could include:
- setting service specifications
- contract management
- resource allocation
- combining the management of current provider cost improvement programmes (CIPs) with commissioner quality, innovation, productivity and prevention (QIPP) efforts
- care coordination
- sub-contracting arrangements.
CCGs would retain statutory responsibility for all these functions, for as long as legislation as per the 2012 Health and Social Care Act stands.
This report is therefore intended to provide a timely contribution to the debate about how commissioning models and commissioner/provider relationships can best evolve to support local populations.
The relationship between clinical commissioners and providers therefore seems on the brink of significant change, with commissioners taking a more high-level, strategic approach, and providers taking on or supporting some more tactical or transactional aspects of the activities previously undertaken by CCGs.
Report aims and methodology
To shine a light on the evolving commissioning landscape, NHSCC and NHS Providers jointly commissioned a piece of research in the summer of 2018. The purpose of this project was to showcase practical examples of collaborative working between CCGs and providers and to explore the current commissioning landscape in the context of system working, including moves to redefine the relationship between clinical commissioners and providers.
This research builds on Steering towards strategic commissioning (NHS Clinical Commissioners, 2017). The infographic and accompanying report on emerging commissioning models found that CCGs are evolving at pace, with a view to developing as a vehicle for a more strategic commissioning function. We return to this topic over a year later to review the current status of commissioning arrangements across systems and to explore the vital and changing role of providers within this context.
Underpinned by a literature review of relevant source materials, a number of in-depth, semi-structured interviews with both clinical commissioning and provider leaders were undertaken to gain an understanding of system working across local areas in England, supplemented by interviews with several national thought leaders. For further reading on this topic please see Appendix A and for a list of interviewees, please see Appendix B. A half-day roundtable event was also held to gain further understanding of system working across local areas – this was discursive and allowed for organic exploration of the topic. A list of roundtable participants can be found in Appendix C. NHS Providers and NHSCC are very grateful for the time and insight offered by everyone who helped inform this report – it would not have been possible without them.
In the context of system working, we are conscious that local commissioning arrangements will need to consider the role of all organisations involved in the local delivery of health and care, including local authorities, and the voluntary and independent sectors. However, this piece of research deliberately focuses on our core areas of expertise: the CCG/NHS provider relationship and the learning from the recent devolvement of specialised commissioning responsibilities to more local levels.