Richard Vize: Are clinical commissioners improving patient services?

Richard VizeClinical commissioners are beginning to demonstrate how they are improving patient services, countering the lack of attention they are getting from politicians.

The health reforms were intended to put clinical commissioners at the heart of the drive to improve quality and reconfigure services. But since they took over from primary care trusts in April, clinical commissioners have not fitted in with the political direction being pursued either by health secretary Jeremy Hunt, or the shadow health secretary, Andy Burnham.

Hunt’s determination not to mention the health reforms means clinical commissioners have rarely been part of his narrative about improving the NHS. Crucially, his response to the Mid Staffordshire scandal has been to focus on regulation rather than commissioning as the way to avoid future crises. Indeed, commissioners often feel disconnected from the work of the Care Quality Commission in their area.

Meanwhile Burnham has been developing a plan to move commissioning to local government, with clinical commissioning groups being reduced to an advisory role.

But CCGs have an ally in Stephen Dorrell, chair of the Commons’ health select committee. Last year he challenged NHS Clinical Commissioners, the representative body for clinical commissioning groups (CCGs), to provide evidence of where clinical commissioning was making a practical difference. The result is their report, Taking the Lead, giving examples of where they are working with providers in “changing the face of the NHS.”

The thread that runs through the 15 examples is that, under the new regime, transactional commissioning focused on money and contracts is giving way to clinicians working with clinicians—and partners such as local government—in planning and delivering improvements to patient services.

The emphasis is on pulling together and interrogating clinical data from across whole systems—hospitals, GPs, specialist and community services—asking searching questions of everyone involved, and taking action.

Key to making that work is commissioners as far as possible leaving their managers to do the management while focusing their own efforts on building relationships with hospital consultants and others. It is the insights gleaned from those relationships, and the trust that develops, that act as the catalyst for change.

A notable case highlighted by the NHSCC is tackling the chaotic A&E service at Norfolk and Norwich University Hospital. Last winter up to 80 ambulances a month waited outside for over an hour. Now it is sustainably down to one or none a month, with far better coordination between paramedics and the emergency department, nurse-led teams meeting patients as they arrive, and an overhaul of the medical assessment unit.

The CCGs being promoted by NHSCC are, of course, among the strongest performers. Some others are struggling, but that variation in performance is no worse than PCTs less than a year after their creation.

One of the biggest complaints about the new NHS structure is the weakness of system leadership when it comes to driving through major change; some people are even beginning to miss the strategic health authorities’ ability to push through tough decisions such as moving services between trusts.

Over the coming months clinical commissioners need to be seen to take on some of that system leadership role, both in their own area and in collaboration with neighbouring CCGs. The highest performing ones are already beginning to do this, as the NHSCC report demonstrates.

Clinical commissioners need to push hard to ensure that the central importance of the local clinical voice in improving services is grasped by national and local politicians and local people, and their role in securing changes such as seven day working and lower demand for emergency services is understood. After a year of relentless criticism of the NHS, good stories need telling.

Richard Vize is a journalist and communications consultant specialising in health and local government. He was the editor of the HSJ 2007-2010.

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