Co-commissioning: the pros and cons

We welcome Dr Junaid Bajwa back to the blog to explain about Co-commissioning

Dr Junaid Bajwa

What are Clinical Commissioning Groups?

NHS Clinical Commissioning Groups (CCGs) are statutory bodies that control £67 billion of NHS funding or around 66% of England’s overall health budget.

The funding is a mechanism by which each CCG can influence and shape services in order to satisfy its statutory duty to support quality improvement in primary care.

There are 211 CGCs, all of which are GP-led. Co-commissioning is when two or more commissioners come together to authorise healthcare services. It facilitates NHS England working with a CCG on the local commissioning of primary care services.

Why Co-commissioning?

The Department of Health outlined four aims of co-commissioning in its 2014 letter to CGCs:

To achieve greater integration of health and social care services, with a focus on making out-of-hospital care systems such as health, mental health and social care more cohesive and improve outcomes.

To raise local standards of quality within general practice services; reduce unwarranted variations in quality; improve the resilience of member general practice providers; and provide targeted improvement support for practices.

To enhance patient and public involvement in developing services, for example through asset-based community development.

To address health inequalities by improving quality of primary care in deprived areas and for vulnerable groups including people with mental health problems or learning disabilities.

How can CCGs co-commission?

There is a spectrum of potential forms that co-commissioning could take, but all need to be considered in the context of the CCG’s five-year plan for its local NHS services.

The plan includes:

Greater CCG involvement in influencing commissioning decisions made by NHS England area teams;

Joint commissioning arrangements, whereby CCGs and area teams make decisions together and are potentially supported by pooled funding;

Delegated commissioning arrangements, whereby CCGs carry out defined functions on behalf of NHS England and area teams hold CCGs to account for how effectively they carry out these functions

How are CCGs held to account?

CCGs already have powers to commission services from general practice or other primary care providers, as well as having a statutory duty to manage conflicts of interest.

It is mandatory that CCGs interested in co-commissioning must set out any additional proposed safeguards for managing potential conflicts in their locality.

Therefore, CCGs need to consider any financial risks in the co-commissioning or primary and specialised commissioned services and the effect of these risks on the functioning of the organisation.

How do conflicts of interest arise?

An extended role for CCGs in primary care comes with risks. Maintaining close links with GP members will be essential for CCGs aiming to drive real change, but relationships might be hard to preserve if CCGs take responsibility for policing their colleagues.

CCGs must demonstrate that they have clear, robust governance processes that show NHS spending decisions have not been influenced by vested interests and avert challenges from providers and the public.

One solution suggested by the King’s Fund is to focus on pathway design and strategy. The area teams and, potentially, commissioning support units, retain responsibility for the mechanics of the procurement and contract management process.

What are Federations, Networks and Clusters?

CCGs have tended to take a facilitative approach to primary care development, encouraging practices to undertake peer review of patient care, discuss comparative performance data and organise group education sessions for their members.

Many CCGs have formed locality groups, networks, syndicates or clusters that act as a liaison between individual practices and the CCG Governing Body or Executive to ensure that local needs are met. It is often at cluster meetings where best practice, ideas and innovation are shared to improve provision and delivery of health services.

As these entities and structures evolve, CCGs can elect to take responsibility for developing their local primary care strategy. They could potentially be negotiating, managing and enforcing local contracts, undertaking financial management and taking decisions on new local providers and practice mergers.

At a time when general practice is struggling to meet growing demands from patients it could be crucial for CCGs to use their leverage as membership organisations to encourage GPs to work in new ways, at scale and in multidisciplinary teams to develop fit-for-purpose primary care and out-of-hospital services.

What are Federations?

These have been bouncing around for some time. The RCGP 2022 GP paper proposes that GP practices come together as federated or networked organisations, working to share back-office functions and educational and clinical services.

Federations potentially offer the win/win situation that maintains local access while creating the organisational scale and capacity needed to reduce the current variation in practice.

Practices would have to collaborate through federations and work at sufficient scale to be able to lead the development of family care networks. They are likely to serve populations of 25,000 to 100,000 and possibly even larger over time.

This offers the opportunity to strengthen the primary role of GPs as providers of care, co-ordinating the delivery of services on behalf of their patients and working in collaboration to provide joined-up services in the community.

For example, hospital specialists such as geriatricians and paediatricians would work alongside GPs towards delivering care closer to home.

How will Federations work?

In different areas, different organisations are setting up different vehicles. The legal advice is to consider the principle that ‘form follows function’ and define the remit that the ‘group’ are undertaking. The primary care toolkit by the King’s Fund, RCGP, Hempsons and the Nuffield Trust provides a thorough description of the process.

A number of legal forms could be used to create a Federation:

Private company limited by shares (CLS)
Private company limited by guarantee (CLG)
Community Interest Company (CIC) limited by shares or guarantee
Industrial and Provident Society (IPS)
Charity
Limited Liability Partnership (LLP)

For example, the Tower Hamlets ‘Primary Care Networks’ have:

Eight networks and five practices per network
Central management funding, with significant funding in 2006/7 (£8m over 3 yrs)
Improved their use and knowledge of Information Technology
‘Networked’ administration staff
Networked the specific educational budget to address unmet local needs
Changed local enhanced services (LES) to Network Care Packages (NIS)
Monthly multidisciplinary team meetings with specialists
Data shared by each practice, with peer comparison and support encouraged
Payment made to the network, with 70% in advance and 30% on achievement

Suffolk GP Federation has a distinctly different structure and has:

A membership organisation governed by a board of nine GPs, three practice managers and a CEO
A population of 539,000 patients to cover
Formed to win contracts for extended services and now also covers diabetes, ultrasound, lymphoedema, cardiology and urology, as well as running a locum bank and supporting procurement

What services could Federations offer?

Technically, Federations can offer anything under AQP (Any Qualified Provider).

For example, NHS South Worcestershire CCG has awarded all its existing enhanced services, worth £2.3m, to a new, single federation comprised of all practices in the region.

The CCG intends to continue all the current local enhanced contracts, which have a total value of £2.3m, by contracting SW Healthcare Limited. This is the provider arm of the local GP federation that is jointly owned and run by all 32 CCG member practices as one ‘prime provider’ of all services.

This is the first known instance of a CCG commissioning all its enhanced services out to a new GP-led provider organisation.

How will conflict of interest be managed?

Doctors have strict professional duties relating to conflicts of interest, including a duty to declare to a patient any financial or commercial interest in an organisation to which they plan to refer that pateient for treatment or investigation.

When treating NHS patients, doctors must also tell the healthcare purchaser. Therefore, it is important to ensure a clear demarcation between GP engagement in providing and commissioning services.

The Department of Health’s paper on Principles and Rules for Cooperation and Competition (2010) sets out a series of principles on which to manage conflict of interest: