The 2012 Health and Social Reform Act provided the landscape for the commissioning of health and social care services. The Kings Fund, in a recently published report, looks at how this landscape has evolved, the drivers for change, and the impact this will have on commissioning in the future.
What is commissioning?
Commissioning is the process through which the health and care needs of a population are identified, planned, purchased and reviewed.
Who are the commissioners?
- Clinical Commissioning Groups (CCGs) – groups of local GPs and other health professionals who are responsible for the commissioning of local urgent and emergency care, acute care, mental health services and community services. Until recently the majority of clinical commissioning within England was undertaken by CCGs with responsibility for approximately two-thirds of the NHS Budget (£73.6 billion in 2017/18).
- NHS England (NHSE) is the commissioner for Primary Care services and specialist services, which tend to be high cost/low volume services such as renal dialysis, transplants etc. NHSE also commission immunisation and screening services from Public Health England.
- Local Authorities commission social care services including both domiciliary care and residential care services. In 2016/17, local authorities spent approximately £15 billion on adult social care. They are also the commissioners for Public Health services including addiction,services, health visitors, sexual health services and school nursing.
Support for the above commissioners is provided through health and wellbeing boards, (local authority and NHS representatives responsible for undertaking a Joint Strategic Needs Assessment (JSNA) which informs the commissioning process). CCGs also have the support of Commissioning Support Units (CSUs) who provide back office functions, such as payroll, HR, etc across a number of CCGs.
Drivers for Change
So what are the factors influencing how services are commissioned?
- The NHS five year forward view (2014) encourages the development of integrated health and social care commissioning with an emphasis on collaboration rather than competition. To support this, the transfer of some/all commissioning of GP services and some specialist services has been transferred to CCGs through a co-commissioning agreement with NHS England. Many CCGs and Local Authorities are also developing integrated commissioning models with new governance models.
- Financial – many CCGs are working collaboratively to deliver economies of scale. This may involve collaborative commissioning where there are similar needs to address, or the sharing of resources such as staff, management etc. Voluntary mergers of CCGs are also starting to happen.
- Sustainability and transformation partnerships (STPs) have been established in 44 areas with responsibility for implementing five-year plans for health and care services. STPs are composed of CCGs, local authorities, NHS England, providers and other organisations to plan services across a local area. The implementation of these plans may require changes to the current commissioning landscape in many areas.
- The Forward View delivery plan (2017) suggests that CCGs should be aligned with STPs through the introduction of formal governance and implementation arrangements to support joint working.
- Development of Accountable Care Organisations (ACOs) may encourage commissioners to contract with a single organisation or partnership of organisations to deliver a range of services for the local population. This will result in commissioners taking a more strategic overview of the local health system rather than contract monitoring the performance of individual services.
- Devolution – In Greater Manchester, new governance structures have been developed to enable CCGs, local authorities, and other local bodies to take responsibility for the entire local health and care budget. Other areas such as Cornwall and Surrey Heartlands are currently developing similar devolution plans.
It has been five years since the Health and Social Care Act was first introduced and during this period there have been a lot of factors, both from inside and outside of the health system, which have exerted an influence on the future of commissioning. The direction of travel appears to be towards the development of more collaborative/integrated models of commissioning over larger geographical footprints to meet local needs, rather than a centrally driven model of commissioning. As more and more of the above drivers come to fruition, such as devolution and ACOs, CCGs will need to evolve to meet the demands placed upon them.
To read the full report from the Kings Fund please click here.