Kidney surgery

The Lost Art of Clinical Commissioning

By: Ben Gowland
Published: Monday, August 4, 2014 - 05:30 GMT Jump to Comments

It is time to rediscover the lost art of clinical commissioning, says Ben Gowland so that CCGs and clinicians can work together to make change happen.

The task of Clinical Commissioning Groups (CCGs) is, unsurprisingly, clinical commissioning.  But what exactly is it?

Is it:

a) Where an organisation that has GPs on the Board designs and procures new service models; the work is primarily done by managers, but is signed off by the GPs?

b) Where GPs design and oversee the procurement of new service models; the premise being that GPs know best, and can use their generalist perspective to outline for specialists how services should be delivered in future?


c) Where clinicians from all specialties are empowered to work together to design services and find mechanisms for putting the new models of care in place?

Seems obvious: c) right?

Of all the craziness of the reforms introduced by the current government, the one glimmer of hope has always sat with clinical commissioning.  The logic of clinicians controlling the money and using it to put services that best meet patient needs in place is hugely compelling.  But the system in place around clinical commissioning conspires to make options a) and b) a much more commonplace reality.

The problem starts with the purchaser-provider split itself and it goes something like this. The commissioners involve clinicians from the providers in the design of a new service model.  So far so good.  But then the commissioners take that knowledge and the new design to put the service out to the market.  The clinicians who helped create a new service model now run the risk of potentially not being involved in the delivery of the new service, and at worst of being out of a job.  It is unsurprising that when operating a process like this it does not take long before provider clinicians stop getting involved in the design/development process!

This can develop into a mind-set that commissioners should ‘tell’ providers what they want, i.e. dictate what services should be provided, in what way and in what location. 

This is used by commissioners as a mechanism for asserting their authority (‘the system should be commissioner-led’), and can go as far as putting whole services out to tender, which in turn further widens the divide between clinical commissioners and clinicians in provider organisations. 

It can also be used by providers who are resistant to change (‘commissioners should tell us what they want’) as an excuse not to change anything.  Barriers between clinicians end up being reinforced not broken down by the introduction of CCGs.

But if the real strength of clinical commissioning is inspired clinicians, from all specialties and all parts of the pathway, working together, supported by real service improvement expertise, using all the levers available to make real change that improves outcomes and experience for patients, then surely the challenge for CCGs is to make this happen.  Whatever the barriers.  However hard it is.  Probably despite the system not because of it.

My partner is a doctor.  Not a medical doctor, but a PhD doctor. Her doctoral research showed that service improvement is effective when it has three vital components in place:

senior top of the office organisational support,

inspired clinical leadership, and

service improvement capacity and capability at project manager level.  

Reflecting on two years running a CCG I think she is right (she tells me this is not an uncommon occurrence!).  The challenge is putting all of these components in place.

It seems that the passage of time if anything is making clinical commissioning as defined in "c" above less not more of a reality.  It is time for us to rediscover the lost art of clinical commissioning, for CCGs to focus on empowering and inspiring clinicians, supporting them with real improvement expertise, to be able to work together to make change happen.

The views and opinions expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of The Information Daily, its parent company or any associated businesses.



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