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Commissioners favour integration over competition

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The leaders of the commissioning groups created under the government’s NHS reforms want to encourage their current service providers to work more closely together, and share more of the health service budget with local authorities.

Health reporting HSJ and LGC logo

The results of the first clinical commissioning group Barometer survey by LGC’s sister title Health Service Journal reveal a strong enthusiasm for integrating services and budgets, with 96% saying they will encorage integration.

Eighty-four percent of respondents said they would increase shared commissioning functions or pool budgets with a local authority.

Significantly fewer leaders plan to use competition to try to improve services, and some are concerned about being required to apply it.

The Barometer is the first survey of CCG leaders, who will control about £60bn of the NHS budget from April. Included in the analysis are the full results of the survey in a downloadable format.

A total of 116 CCG leaders from 101 organisations responded to the survey. Sixty-five percent were GPs.

Forty-seven percent were CCG chairs, 38% were accountable officers, and the remaining 15% were other senior executives or governing body members.

Asked to rate a set of possible methods for improving services, 96% of the CCG leaders said they were likely to encourage increased integration of their existing providers in the next year.

Pie charts: How will your CCG change services in the next year

A significant but smaller proportion - 50% - said they were likely to make greater use of alternative providers and increased competition.

When asked to rate a series of potential blocks to their ability to improve services, 73% of respondents said “requirements to introduce more competition and competitive procurement” were a barrier. Eighty-two percent said the NHS “per treatment tariff system” - a commonly cited problem in creating a more seamless approach - was a barrier.

‘There’s still some lack of understanding about how beneficial competition can be in the right circumstances’

Just 23% said “not enough opportunity to introduce competition and new providers” was a barrier.

Bar charts: What factors will be a barrier to change in the next year

NHS Commissioning Board national director of commissioning development Dame Barbara Hakin said the results might reflect the unjustified concern of some leaders that they would be forced to introduce competition in areas they did not want to.

“There’s still some lack of understanding about how beneficial competition can be in the right circumstances,” she said.

Several CCG leaders told HSJ that while they realised introducing competition was useful in some circumstances, they were more enthusiastic about working with existing providers.

NHS Vale of York CCG accountable officer Mark Hayes, a GP, said: “Competition has its place, but integration makes more sense if you want to have a seamless service.”

NHS Kingston CCG accountable officer David Smith, who is also Kingston upon Thames RBC’s director of health and adult services, said the organisations wanted to commission a single existing social enterprise as their joint community and social care provider.

He said: “If you open it up to the market you can get a more fragmented service. We will get better outcomes and value if we work through a single provider.”

‘We will get better outcomes and value if we work through a single provider’

NHS Clinical Commissioners (NHSCC) interim president Michael Dixon urged the commissioning board and Monitor not to force CCGs to use competition. He said: “Where you’ve got a reasonable service the best way of improving it and making it more cost effective is to integrate.

“I hope [Monitor] will get it right but NHSCC will be coming down like a tonne of bricks if they don’t.”

Royal College of GPs chair Clare Gerada said: “It is very positive news that GPs are focusing on joining things up rather than further fragmenting care.

“We need to work together - removing the barriers that promote fragmentation and increase costs, which the Health Act will do in spades.”

CCG leaders’ hopes and fears

  • “The key to improving quality and productivity is changing the way providers work. The greatest barrier to achieving this is the perverse system incentives.”
  • “Current providers will use all their skills in raising fear among the population about cuts to their services, and try to highlight the inherent dangers in the proposed new community services.”
  • “A reduced health allocation to a northern CCG in the context of a local authority facing [efficiency savings] of £100m is a major concern.”
  • “Capacity; having an LAT [local area team] with the balls to trust and support us; having a government that doesn’t impose any more top-down programmes.”
  • “Over a 24-36-month period, I would have no confidence in our ability to stay in budget. [That] will need major changes to the way healthcare is delivered. These would breach the NHS constitution.”
  • “Our biggest issue is lack of capacity in change management personnel and our inability to put real physical support in the shape of people into our practices.”
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