Policy in action: CCGs

Though in its infancy, Newham Clinical Commissioning Group (CCG) feels well established. Someone’s having a birthday, and staff have gathered to hand over cake and presents; Newham CCG marketing and communications material seems to cover every shelf and noticeboard; and small groups huddle in intent discussion around the vast, open-plan office. Tucked away at the back is a meeting room big enough for four. Six of us squeeze in — working behind closed doors doesn’t seem to be the done thing here.

“We are the ones who saved Barts Health NHS Trust,” proclaims Dr Zuhair Zarifa, chair of the CCG. He’s talking about the impressive reduction in the number of Newham CCG patients attending local A&E units, including those of Barts – a reduction that has brought Barts’ A&E waiting times back within target. Newham now has some of the lowest rates in London. Riding high and confident, Zarifa’s not shy of singing the Newham CCG’s achievements from the rafters.

Also at the table are chief officer Steve Gilvin; Dr Elizabeth Goodyear, partnerships commissioning lead and clinical lead for maternity; and Satbinder Sangher, director of partnerships and governance. Collectively, they are determined to show me why their optimism is warranted.

 

Shift in approach

Newham CCG has been running for just over a year, since its creation on 1 April 2013 under the 2012 Health and Social Care Act. It includes 61 GP practices, and covers a population of 318,000 — expected to grow to 382,000 by 2021. This is the third most deprived local authority area in England, and has the highest birth rate and a higher than average population churn — all factors linked to poor health in a local population.

Though the cornerstone of the new health system, CCGs make up just one element of the system that replaced Primary Care Trusts (PCTs) and Strategic Health Authorities (SHAs). Previously, PCTs commissioned primary, secondary and community health services, controlling 80% of the NHS budget, while the regional SHAs oversaw policy on behalf of the Department of Health. But now commissioning is carried out primarily by GPs, with every practice operating as part of a CCG. Through these partnerships, CCGs now spend about 60% of the NHS budget: not all the PCTs’ responsibilities were handed to them.

While the 221 CCGs are responsible for commissioning the bulk of health services, local authorities take responsibility for health improvement; Public Health England handles health protection and promotion; and NHS England commissions specialist services.

So the NHS has seen a wholesale transformation, costing at least £1.5bn. The point of all this disruptive and costly change, former health secretary Andrew Lansley argued, was to get away from the PCTs’ top-down, management-led approach to commissioning. Putting local medical professionals in the driving seat, he believed, would both ensure that services meet local requirements, and refocus the NHS’s efforts on clinical needs rather than hitting targets set in Whitehall.  

“The local hospital need to know they cannot take us or the patient for granted”
Dr Zarifa

Certainly, Goodyear says she feels liberated to act in her patients’ interests: the PCT “tended to always inhibit innovation and making efficiencies and improving quality,” she says. And Zarifa clearly also felt stifled by the commissioning body looming above: “The system had to change, we couldn’t just keep on with the PCT — some manager sitting there in an office,” he reflects. “Clearly to [Lansley], the best people who could change the system are the clinicians, because we have credibility and knowledge about health needs.” He’s no financial expert, he says, but he does understand patient care – and now he has the freedom to identify the best solution for each patient. “And people will believe us, because they’re aware we’re their advocate,” he adds.
The CCG staff also point out that the financial pressures on the NHS are only going to grow. “People living longer; everything is far much more expensive than it was before,” Zarifa explains. “I remember when I started as a doctor, the average [life expectancy] for men was 73 and the average for women 75. Now we say to our 73-year-olds: ‘Oh, you are very young now’.” Many will live into their late 80s, and those extra years are “very expensive for patient care and so forth. So things have to change. They can’t be maintained by just keeping on crunching a machine and printing more money.”

In Zarifa’s view, GPs’ proximity to patients makes them the best people to work out how to spend money most efficiently. And because the solutions are coming from frontline staff rather than being handed down from above, he believes, reforms and innovations are more likely to win over medical practitioners. “We experience patients from Monday morning to Friday afternoon, so we know exactly what works and doesn’t work for the patient,” he says. “That’s really the fundamental difference between the PCTs and the CCGs.”

Nonetheless, Newham CCG faces a tough task: its budget for 2014-15 is £391m, and it’s not expected to rise in line with population growth in coming years. “We’ve had to run hard to stay still,” reflects Gilvin. “We haven’t been cut, but we haven’t had growth. And in a rising population, it’s a really big financial challenge.”

In some areas, the CCG may cut costs by commissioning services from private providers rather than NHS trusts – but Zarifa is quick to make the point that he has no ideological preference for buying from businesses. “We welcome private, but they get no extra credit for being private,” he says. “We don’t want to replace the local hospital. But the local hospital need to know they cannot take us for granted, and they cannot take the patient for granted; people want better services and we have to fight for them.”

 

At the heart of the community

In some ways, Zarifa suggests, holding his own budget has made him more aware of the costs attached to his decisions. “It’s an exposure for us,” he says, remembering how he used to operate when the PCT provided all his support services: “Before, in my surgery I would say: ‘Do this’, and tomorrow morning it would happen.”

Zarifa’s surgery, Custom House Teaching and Training practice, is a stone’s throw from the Newham CCG office. It services around 13,000 Newham patients; he has been a partner there since 1990. Nestled between a cafe, a dry cleaners and other amenities typical to a semi-busy boulevard, it has the feel of being at the heart of the community. In the waiting room, I approach a woman to ask about her experiences. She looks on as I explain, and responds with three simple words: “No speak English.”

This is indicative of the challenges faced by a CCG servicing a community where more than 100 different languages are spoken; the borough also has the largest transient immigrant population in London. And this, again, helps explain why local GPs sometimes chafed against the controlling hand of the PCT: “One size doesn’t fit us,” stresses Goodyear. “We have 30% of our population changing every year. We’ve got non-English-speaking patients. Trying to educate people continuously is very difficult.”

One of the problems resulting from Newham’s highly mobile, ethnically diverse population was a tendency for people to attend A&E with non-emergency conditions – often because they weren’t aware of primary healthcare services, or registered with a GP. Hence Barts’ difficulty in hitting its waiting time target, which requires 95% of patients to be seen within four hours.

The CCG’s solution was to produce an urgent care strategy, involving a dedicated network comprising Barts Health NHS Trust, East London NHS Foundation Trust (ELFT) and the London Ambulance Service. The aim was both to ensure that minor illnesses are dealt with in primary care, and to improve the care for GP patients with long-term conditions – reducing their propensity to show up in A&E.

The first stage of the strategy was to procure and open a GP-led urgent care centre (UCC) for adults and children at Barts Trust’s Newham General hospital. By diverting patients from A&E, the UCC has helped Barts get its four-hour performance up to 98% – putting it well above a target line achieved by only two thirds of NHS providers.

 

A voice for all stakeholders

Another aspect of the NHS reforms was the desire to give patients a voice in key decision-making forums. Gilvin points out that the patient group Health Watch is a voting board member of the CCG, but Sangher suggests that the group needs to go further in fostering public engagement. “The reality is that the board only meets once a month. It may meet less in the future,” he says. “Plus, you can only have so many people on your board. You’ve got to find other mechanisms.”

Meanwhile, the CCG itself feels excluded from some decisions about the care delivered within its area. “Chemotherapy, for example, is commissioned by a London-wide organisation,” says Gilvin. “What do they know about the right place and the right way in which chemotherapy can be delivered to Newham patients? They end up coming back to us and saying: ‘Can you just tell us what you think about it?’.” In moving up from the PCT to the conurbation-wide level, this form of care has actually ended up further removed from GPs. “We’ve missed having some of those functions,” says Gilvin. “So there are some things about the reorganisation that haven’t worked. I would hope that as we mature as an organisation, we will have the opportunity to take some of those things on.”

In other areas, though, CCGs are handling areas of healthcare previously directed at a national level. Take type 2 diabetes, which is particularly prevalent in the South Asian and Afro-Caribbean communities – both substantial in Newham. Working with neighbouring CCGs, Newham has invested heavily in a ‘care pathway’ designed to cut the number of patients who require life-changing – and expensive – interventions such as amputations. Zarifa is confident that while the pathway is expensive to set up, there will be savings in the long run.

Initiatives like this make the move to the CCG model feel like an exercise in localism. Not everyone, however, is a fan of this bespoke approach to commissioning. Nikki Joule, policy manager at healthcare charity Diabetes UK, points out that just as CCGs came into force in 2013, the NHS’s diabetes national strategy expired.

“I hope that as we mature as an organisation, we will have the opportunity to take some of these things on”
Steve Gilvin

According to Joule, while particular groups are more susceptible to the disease, 25% of the UK population is at high risk of diabetes – which costs the NHS about £10bn a year: more than 10% of its budget. So it is a truly national problem. And while Newham may be acting to cut the number of people who suffer from complications, Joule argues that under the CCG system, there are growing inconsistencies in the quality of service around England.

“The introduction of CCGs has increased the variation [in provision] across the country,” she says. “There are nine care processes that are recommended under the National Institute for Health and Care Excellence [NICE] guidance, that everyone with diabetes should have. But there is huge variation across the country [in how these are implemented] under the CCGs. It means that if you live in one part of the country, your risk of having complications is higher just because the basic diabetes care isn’t as good. Sometimes you get neighbouring areas with very different performance.”
She adds that despite particular groups being more susceptible to diabetes, “80% of type 2 diabetes is related to obesity,” making diabetes a more general issue. “It’s not necessarily that helpful to have 211 different organisations setting their own priorities and plans,” she comments. “There is not that much that is different about how you would manage diabetes from one geographical location to another.”

 

The big compromise

These contrasting views around the provision of chemotherapy and diabetes care illustrate one of the tensions within the new NHS system. Many medical conditions are tied to local environmental and lifestyle factors, with preventive work often best handled via direct contact with patients – but those same conditions are often best treated by highly-specialised teams using extremely expensive equipment, which are best provided in a few centres of expertise.

This dynamic means that every approach is a compromise. Newham CCG may be providing its diabetic patients with better care than they’d receive under a national delivery strategy, but in other parts of the country people are probably worse off. And whilst Newham’s GPs rail against the citywide chemotherapy system that offers locations and services not best suited to their patients, the fact is that bringing together the capital’s chemotherapy services is likely to improve clinical success rates.

In this environment, the Department of Health has tricky choices to make – and will face ongoing pressure – over where to intervene with a national strategy, and where to follow the logic of its bottom-up commissioning system. Back in Newham, though, the CCG’s medics are convinced that putting them in the lead is best for patients, and ready to take responsibility for the results. “GPs are the majority in [CCGs] because who is better to be placed for patient services?” points out Zarifa. “In that sense, if it fails then it’s the failings of the clinicians. I can’t turn around and blame [CCG managers Gilvin or Sangher] for it. We have to blame ourselves for it.”

Even accepting the CCG model as the right one, concerns remain about whether it’s quite meeting some of the Department of Health’s promises – particularly those around empowering patients, whose participation in Newham CCG’s decision-making is largely mediated through the board role of a patient advocacy group. But the CCGs are now up and running; and in Newham at least, the group is taking advantage of its new freedoms to create bespoke care pathways and local strategies that should improve care and cut costs in ways that no top-down system could facilitate.
Eighteen months in, Newham CCG’s staff are convinced that they’re making good progress. But it’s been hard work getting this far, and there’s a cloud on the horizon: at last month’s Labour conference, shadow health secretary Andy Burnham said a Labour government would pass commissioning responsibilities to councils and give hospitals more power – signalling the effective end of CCGs dominance, and heralding yet another vast, top-down NHS reorganisation.

“What we can’t have is somebody throwing in a new idea just before the next general election, and then coming up with a new system,” says Sangher, with some anxiety. And whatever you think of the new NHS system, it’s clear that the reforms that created it have cost billions, stretched NHS staff, and led to delays and disruption affecting planning and services across the country. Whatever the next government decides to do, it would be well advised to make good use of the commitment, local knowledge, and hard-won commissioning expertise built up in the nation’s 221 clinical commissioning groups.