Commissioning in a reformed NHS

The central part of the Government’s NHS reforms – the introduction of Clinical Commissioning Groups (CCGs) – has focussed on transferring commissioning away from largely managerial control into the hands of clinicians, principally GPs. These CCGs will be accountable to the NHS Commissioning Board who will also control which CCGs are authorised to spend NHS money.

Whilst the process is still to be determined, the CCGs will have to satisfy the Commissioning Board they are competent across a number of factors (similar to the duties of a Primary Care Trust). Those CCGs that do not wish to commission services or are not deemed competent to do so, will have their commissioning functions performed by the NHS Commissioning Board. This will create a two tiered approach to commissioning and importantly could affect the way in which they interface with patients and customers.

Specialised commissioning

The £10.5bn worth of spending that was handled by Specialised Commissioning Groups (SCGs) will be controlled by the NHS Commissioning Board which should result in greater consistency in policy and reduced transaction costs. However, questions will be asked like: Whether the services from SCGs will be transferred en masse or be re-created by the Commissioning Board? Could this be a target for cuts in future years as Public Spending cuts get stiffer?

Commissioning Support Organisations

Since authorised CCGs will be free to determine how they carry out their responsibilities – including the purchase of commissioning support – the development of this market will be a key battleground. The expectation is that commissioning support will be provided by a range of organisations – private sector, voluntary and public sector spin offs in the form of mutuals.

The NHS Commissioning Board is to offer arm’s length support to Commissioning Support Organisations (CSOs) which are effectively the remainder of in-house PCT and SHA staff. This arrangement does, however, raise a number of issues from a legal, conflict and competitive point of view.

Competition in the NHS

During the passage of the Bill, Monitor (now to be known as the ‘sector-wide regulator’) will have economic responsibility for both health and, in the future, adult social care with a core duty to protect and promote the interests of patients.

Concerns that competition would be pursued has been allayed with changes which seek to limit ‘cherry picking’ of easy but profitable cases by the private sector. Prices for NHS services will now be set by agreement between Monitor and the NHS Commissioning Board, perhaps with some form of weighting to the NHS tariff to reflect complexity of case mix.

Monitor will continue to act as the regulator for Foundation Trusts with the timetable for all hospital, mental health and ambulance trusts reaching this status by April 2014. Approximately 40% of acute trusts have still yet to attain foundation status and how and whether these organisations are granted freedom from the NHS Commissioning Board will be another test of the Government’s reforms.

Any Qualified Provider

The Government’s goal is for patients to be offered a wider choice of providers – public, private or voluntary – when they are referred for NHS treatment by a healthcare professional. It is this policy, more than any other that has opened the Coalition up to accusations that the NHS is being privatised.

Private, voluntary or mutual organisations wishing to provide NHS-funded services will now have to be licensed by Monitor and the Care Quality Commission via a joint licensing process. While providers will have concerns about an all too onerous regulatory regime, the phased implementation of Any Qualified Provider, which is already underway, only opens up the NHS to a very small additional amount of competitive pressure in the short term.

A further list of services to be opened up to patient choice from 2013 onwards includes maternity (antenatal education and breastfeeding support); self-management support for long term conditions; and community chemotherapy, including home chemotherapy.

The future

The big challenge comes from the public and professionals equating the changes coming from the Act with austerity and cut backs required in order to meet the £20bn efficiency target. From a policy perspective, the Nuffield Trust and King’s Fund will probably continue their push for a faster move towards integrated care. And since is now likely – determining how this is done should have been a priority from the start.