A historical perspective
Clinically led commissioning had its roots in the last Conservative Government with the introduction of fundholding. This empowered individual GPs and practices to introduce new local services and to put pressure on hospitals to do better. Yet it had flaws. It pitched GP practice against GP practice and complex patients became ‘unprofitable’ and sometimes fell between the cracks in the service. It was also professionally compromising because the less that a practice spent on services for its patients, the more income the GPs in those practices were able to take home. Many fundholders, however, were committed to improving care for their patients but, compared to current reforms, it was possibly too unambitious as it did not affect most patients on a GP list and hardly scratched the surface of improving local health.
‘Non fundholders’, meanwhile, had developed their own movement as a reaction to the perceived failings of fundholding. Recognizing that they could not be ‘nons‘ forever, we invented a more positive term:- ‘GP Commissioners’. The movement rapidly gained momentum during the late 1990's and by the time of the Labour Party election victory in 1997, GP commissioners were running 112 local commissioning groups, which covered a total population of 12 million in England with half of them being fundholders and half non-fundholders. Their mission was for frontline GPs to be able to improve the services and health available to the local population in addition to an individual GP's role in treating each patient. GPs in this role were largely advisory, rarely holding anything that amounted to hard budgets, and survived as a movement because of enthusiasm, a large degree of altruism and much burning of midnight oil.
With the advent of the 1997 Labour Government, GP/Locality Commissioning became mainstream with the introduction of Locality Commissioning Pilots under the then Secretary of State, Alan Milburn. Generalizing this model led to the creation of Primary Care Groups, which were sub-committees of the then Health Authorities led by a majority of GPs. Frontline clinicians throughout England, for the first time, had been given a real potential to improve local services and health. This opportunity was short lived.
Unfortunately, Primary Care Groups only lasted a year or two. Suddenly, there was an imperative to integrate this commissioning role of PCGs with the provision of community services. This created Primary Care Trusts led by Chief Executives in contrast to the Primary Care Groups that had been led by Clinical Chairs. Despite warnings, a few years later, it became clear that Primary Care Trusts had ‘lost’ their clinicians and were hampered by a conflict between their provider and commissioning roles. Consequently, ‘Transforming Community Services’ saw the hiving off of those community services that had been acquired by PCTs to other providers – mainly to acute service providers, Mental Health Trust providers and Foundation Community Trusts. At the same time, there was a half hearted attempt to re-engage clinicians through practice-based commissioning.
As the Coalition Government came to power, it was clear that practice-based commissioning was not working. Clinicians were neither engaged nor empowered and felt little ownership of a health system that was dominated by hierarchical structures and management led by Whitehall.
Current reform
For disappointed GP commissioners of the 1990's, the Coalition Government seemed to offer a new hope. It recognized that something radical had to be done if clinical commissioning was finally to come of age. Firstly, the NHS had to lend more than lip service to the idea of clinical leadership. Hence Coalition proposals that PCTs should be replaced by Clinical Commissioning Groups with the latter gaining statutory status. Thus, for the first time, solidifying clinical leadership and stamping clinical commissioning on a system that had seemed so reluctant to allow clinicians any meaningful leadership role. It was, perhaps, little wonder that senior managers, their organizations and their supporting media were not very happy.
A second aspect of the Coalition reforms was the recognition that redesign of the Health Service required a movement of care, where safe and appropriate, from hospitals to community and, wherever possible, to make patients as self-sufficient as possible with minimal professional input. This inevitably sparked off fury among entrenched and old-fashioned specialist interest groups and the Coalition found itself being faced with an unholy alignment of senior managers and (particularly secondary care) clinicians. With the production of a weighty ‘Health & Social Care Bill’, a further factor entered the debate. The Government's commitment to markets and competition led to panic among clinicians, unions and some patients that the NHS was about to be privatized. These fears might have been allayed simply by saying that the new clinical commissioners would be in the driving seat, so any increase in privatization would be only by their hands. Instead, it seemed to many that Monitor, European Legislation and maybe the National Commissioning Board could all trump the decisions of clinical commissioners and effectively make them put markets before patients. The Government moved to correct this perception but not before a wider community of clinicians from both primary and secondary care and unions were on their backs. Some might say, however, that the Coalition Government was really doing no more than putting the finishing touches to concepts of market challenge that had been already introduced by Tony Blair and Alan Milburn.
These events put clinical commissioners in a very odd place indeed. All the things that they had fought for, for so many years, seemed at last to be being championed by the new Coalition Government. Yet the reforms were meeting the full antagonistic blast of the NHS clinical and managerial community. Worse still, the clinical commissioners saw their moment of ‘liberation’ disappear as those reforms were challenged by the Future Forum and the Government responded by pacifying the secondary care lobby with the promise of clinical senates that could wrong foot the new Clinical Commissioning Groups and stipulating that a consultant (provided that he/she had nothing to do with the area that the Clinical Commissioning Group covered) could sit on the Clinical Commissioning Board (CCG Boards) as of right. Clinical commissioners began to feel that no one was fighting their cause and as the Bill was passed from the Commons to the Lords, those speaking out for clinical commissioning and the Reforms began to be regarded as ‘scabs’ by their colleagues. The winter of 2011/2012 seemed to spell a sorry end for a ‘commissioning movement’ that had simply wanted to improve the care of patients and the health of local communities.
With the arrival of Spring, and the final passing of the Health & Social Care Bill, does this mean that clinical commissioners, clinical commissioning groups and the leaders of those groups can now move out of the gloomy shadows and bask in the sunshine of a reformed NHS? Having survived the slings and arrows of outrageous fortune so far described, surely they should? Life, of course, is never simple.
That is because, with the Bill passed, the very same forces that opposed it will now be free to trip up its implementation. It has all happened before. A successful seed, be it a clinical commissioning group or anything else, needs healthy soil. But the NHS's soil has not significantly changed. The signs are already there.
The four or five hundred clinical commissioning groups that originally set out have now been homogenized into less than 250 because PCT clusters and Strategic Health Authorities deemed many of the earlier clinical commissioning groups to be too small. It appears that there are senior managers in the system that simply want to create again the very same system that they have always known. It is little surprise, perhaps, that the current number of clinical commissioning groups is so similar to the original 250 PCTs created in early 2000. Furthermore, the new management hierarchies – the National Commissioning Board, Sectors and PCT Clusters look all too similar to the ‘old world’ and poised to line-manage and oppress clinical commissioners trying to lead at the NHS' frontline. Secondary care clinicians remain visibly the ‘senior service’ within the new National Commissioning Board. For CCGs leaders, processes of authorization in creating organizations fit for purpose are distracting CCG leaders from the far more important task of creating new bonds between frontline clinicians. Bonds that PCTs were rarely ever able to create. Bonds that are so crucial if we are to inspire frontline clinicians in their new role of protecting the health and wellbeing of their patients and improving the services available to them.
The future
Does all this mean that clinical commissioning groups and their leaders are doomed to the back pages of NHS history just like most NHS reform since 1948? Perhaps not for good theoretical and practical reasons.
Firstly, go back to the original theory. If clinicians are the main determinants of NHS spending through their clinical decisions with individual patients, then it makes sense to give them a leadership role in ensuring that NHS resources are used to best effect. Unless clinicians are prepared, in some respect, to balance the good of an individual patient with the good of the local community and wider NHS, then the NHS is truly doomed. Especially so at a time of economic decline and increasing demand. Furthermore, the health service must push the boundaries in terms of treating patients in communities rather than hospitals wherever possible and in de-professionalizing care wherever it is appropriate. These things have not been achieved through the centralist command and control model and can only be achieved by better balance between local and central. The theory that underpins clinical commissioning and clinical commissioning groups is pretty unarguable. It represents the NHS's best chance and opponents have yet to explain how they can square the circle of cost and care in any other way.
Secondly, there are the practical issues. The NHS needs to save a lot of money and cannot do this without having clinicians signed up to helping. The new clinical commissioners will need urgently to forge much more productive relationships between primary and secondary care clinicians and between health and social care if they are to provide better and more cost-effective care for their patients. Health and Wellbeing Boards offer the best opportunity to date of accelerating this process with a potential for innovative local health initiatives. If clinical commissioners and Local Authorities can encourage health creating communities, then we would see the NHS achieving its real potential with its clinicians (in primary care at least) having every incentive to improve outcomes but without necessarily increasing professional activity and cost. If clinical commissioning groups can add to their achievements a radically new way of involving patients and local people in individual treatment decisions and commissioning services, then clinical commissioning will have come of age and will deliver its full potential.
So for commissioning leaders, 2012, post the Health & Social Care Bill, should offer a new lease of life and release energy and enthusiasm that has had to lay dormant during those repressed commissioning years of the last decade. It is unfortunate that the maturation of clinical commissioning from a popular rebel movement to becoming mainstream and statutory should have led to its apparently diminished popularity among many frontline clinicians. Clinical commissioning leaders will now need to restore that spark of enthusiasm and ownership to every frontline clinician, which was so evident during the early commissioning years. This must be their focus rather than the bureauocratic procedures of the National Commissioning Board authorization process.
For GP commissioners, from now on, it is equally crucial that we do not forget our roots’. Those are our roots in the every day consultation bringing primary care clinicians and their patients together, which now provide us with a real opportunity for liberation. That is liberation which starts with frontline clinicians and which will realise the aspirations of those early 1990s commissioners.
We will now need to harness the energy of those that fought against the Bill and those who were in favour, and use that combined energy to drive the full force and fury of commissioning into implementation. That is because, pro-Bill or anti-Bill, the only real defence against fears of imposed competition, marketization and privatization will be strong self-confident clinical commissioners leading strong self confident clinical commissioning groups. It will be the only means of avoiding fragmentation, of ensuring the integration of primary and secondary care services and the integration of both with social services. Whatever the feelings of any clinician during the passage of the Bill, we all now have a duty to see clinical commissioning groups succeed and to ensure that they do work on behalf of frontline clinicians and our patients. With clinical leadership embedded in statute, the future no longer depends on Government, the National Commissioning Board or anyone else. It now depends upon our ability as clinicians to make clinical commissioning work. It is time for clinicians to see this as an opportunity not a threat. Those, at least, who want to see a sustainable thriving and fair NHS. Are we mice or men?
DECLARATIONS
Competing interests
MD has been involved in the commissioning movement since the early 1990s and Chair of NHS Alliance since 1998
Funding
None
Ethical approval
Not required
Guarantor
MD
Contributorship
MD is the sole contributor
Acknowledgements
None