The mood among clinical commissioners less than a month into the new system is characterised by a determination to move care out of hospitals, frustration at legal and financial impediments to making change happen, and considerable confidence that they can make a difference.
At the first conference of NHS Clinical Commissioners—an independent group launched by the NHS Alliance, NHS Confederation, and National Association of Primary Care—introspection was refreshingly absent. While there were concerns about workload and the risk of conflicts of interest as commissioners invest in primary care, the focus was very much on the big picture of their new role. In particular, fears voiced by the BMA that commissioning could lose GPs the trust of their patients did not surface as a major issue.
Instead, commissioners recognise that one of their risks is a divide opening between themselves and their member practices. Winning GP trust and involvement is already proving tough. If the new emphasis on providing care in the community and reducing emergency hospital admissions is not to lead to excessive GP workloads, CCGs know they have to encourage practices to adopt new ways of working such as greater collaboration, a bigger role for practice nurses and pharmacies, and more effective use of technology—such as the telephone—to interact with patients and other clinicians, notably hospital consultants.
So CCGs need to get GPs to see advantages in the new system, feel part of developing a new patient-centred approach, take on new work, and change the way they run their practices. And they have to do all this while GPs are angry about changes to their contracts. So it was not surprising to hear concerns among commissioners that they risked being braver in addressing the need to reform hospitals than in reforming GP services.
It is a close call whether member practices or trusts will be tougher to win over to change. Like the businesses they mimic, trusts equate growth with success. Pushing the idea that, for some, their future lies in being smaller, but more profitable and sustainable is proving a hard conversation to start. More positively, CCGs recognise that the entrepreneurial skills nurtured by the foundation trusts could be a powerful force for innovation; the question for commissioners is how to channel that to achieve the desired outcomes.
Alongside the competition regulations, the greatest object of loathing for CCGs is the payment by results system. At the NHSCC conference they left health secretary Jeremy Hunt in no doubt that as long as it continues, trusts will have an incentive to game the system and be uncooperative with commissioners.
Hunt agreed it is a barrier to integrating care. NHS England is reviewing the funding allocation system for CCGs, but their appetite for radical change is far from clear.
The determination among commissioners to move care out of hospitals is palpable, but for some CCGs building a meaningful picture of existing services is being severely hampered by inadequate financial and clinical data. It is impossible to plan change if you don’t trust the numbers. As well as increasing the danger of service failures, data weaknesses stand in the way of beginning a discussion with local people and trusts about what needs to change.
One thing that needs to change is the attitude of NHS England. There are already numerous examples from around the country of demands for data without offering a reason, instructions to attend meetings at short notice, and a general lack of recognition that the hierarchical relationship that existed between the centre and primary care trusts is supposed to have been replaced by a more balanced and mutually respectful approach. NHS England is going to build up resentment if that sort of behaviour continues. GPs will quickly express their dissatisfaction if the promise of local autonomy lacks substance.
The need to engage with the public and local MPs and councillors early and relentlessly is almost universally recognised. Some commissioners detect a subtle change in public perceptions about the NHS in the wake of the Mid-Staffordshire scandal. There is anecdotal evidence of greater sensitivity to questions around quality and safety and somewhat less willingness to assume that everything is perfect in their local hospital.
Such a change would of course be helpful to commissioners as they try to generate discussion around the future of local services, but it must not tip into undermining confidence as a means to secure change—an immensely delicate balance.
Richard Vize is a journalist and communications consultant specialising in health and local government. He was the editor of the HSJ 2007-2010.