Feature / In the driving seat

CCGs are leading local efficiency programmes, but with GPs now in charge, has the planning and delivery of savings changed? Seamus Ward reports


NHS England’s recent announcement that the estimated funding gap between 2013/14 and 2020/21 is £30bn will not be a surprise. The need to continue to make savings beyond 2015 is well known. However, putting a figure to the challenge puts pressure on clinical commissioning groups before they are even six months old.

They are leading the QIPP (quality, innovation, productivity and prevention) programme. And they will have to act decisively not only to help deliver the balance of the original £20bn Nicholson challenge up to 2015, but also the further savings required in the following six years.

QIPP is a live subject – CCGs still report QIPP figures each month, though in much less detail than their predecessor primary care trusts. But when talking to CCG finance leaders about their approach to QIPP, one word comes up more often than any other – collaboration.

Undoubtedly their smaller size and limited management budgets mean CCGs are more open to partnerships. But they also believe savings will only be achieved by working with other NHS bodies, local authorities and the independent and voluntary sectors.

Another recurrent theme is managing clinician expectations. Newly empowered GPs are champing at the bit in many areas, but can become frustrated with the relatively slow pace of change compared with that taking place in their own practices.

As made clear in the authorisation process, CCGs are at different stages of their development. Some have hit the ground running, bolstered by clinician involvement in local commissioning over several years. Their strategies are evident in services already commissioned in the current financial year.

Meanwhile, other CCGs are looking ahead to the 2014/15 commissioning round and beyond before they can make an impact.

Business as usual

Tony Matthews, chief finance officer of Stoke-on-Trent Clinical Commissioning Group and North Staffordshire Clinical Commissioning Group, says much of his CCGs’ efficiency work is a continuation of plans set in train by the predecessor PCTs.

‘A lot of us now in the CCGs were involved with the design of that strategy because we had well placed practice-based commissioners who were at the heart of the discussions,’ he says.

Mr Matthews believes a CCG’s efficiency strategy is likely to be heavily influenced by the financial position of their local acute providers.

‘University Hospital of North Staffordshire is not in a great place financially. A lot of what we are about is to move its footprint so there is less reliance on urgent care systems and pathways. We want to manage more patients in the community – but that’s the prize for everyone.

‘We think it’s right to invest at scale in community services so that patients are cared for in their homes or in the locality in which they reside. This will mean that we have to look long and hard at our community hospital provision – and our GPs are behind this. I am led to believe that we have the highest number of community beds per capita in the country.’

This has led the CCGs to shift their approach. ‘We won’t need community hospitals in the way we do now. Locally, we typically pay £1,800 a week for a community hospital bed. But if we had a different way – a nursing home model with wraparound care – it drops to about a £1,000 a week.’

The CCGs plan to invest in intermediate care and community and district nurses, who will be the bedrock for integrated teams.

Chris Melling, associate director of financial sustainability and performance at Wigan Borough Clinical Commissioning Group, says: ‘I think there has been a significant change between the PCT and CCG in Wigan, resulting from the change in board membership. The governing body is now largely made up of GPs and is also chaired by a GP. That is significant in that it moves the decision-making process towards the clinicians.’

Engaging clinicians

Delivering change is not confined to clinicians who sit on its governing body. Wigan Borough CCG has developed a process to engage clinicians in its QIPP and change programmes.

The CCG’s 2013/14 QIPP process began with a workshop last November, which brought together just over 100 GPs, nurses, practice managers and CCG staff to generate ideas for the 2013/14 QIPP programme. In preparation for the event, the CCG pulled together information from a number of sources, including the NHS atlas of variation, programme budgeting data and Better care, better value information, to identify outlier services or those that were not performing well.

The information was shared widely before the event. ‘We try to provide the information to aid discussion and stimulate ideas,’ Mr Melling says. At the event, the attendees were divided into groups to look at specific matters, such as diabetes, respiratory care or cancer. About

175 ideas were generated and distilled into business case development workstreams, with each headed by a GP.

‘By engaging with the primary care and bringing into the work programme provider clinicians where appropriate, we have built an approach to making change. One of the pitfalls of the past was PCT staff trying to make changes without sufficient clinical ownership and involvement,’ Mr Melling says.

Staffordshire’s Mr Matthews says collaborative work is important. ‘Gone are the days when acute providers would be expected to deliver 4% savings on their own. Doing it as a local health system is the only way we can get through this period, but it’s a paradigm shift for some providers.’

Wigan has set up a QIPP programme board, which brings together the chief executives of the CCG, local authority and mental health, acute and community providers.

Mr Melling says: ‘This is a strategic board, driving forward change. It is concerned with longer-term, borough-wide schemes, such as developing better falls programmes and long-term conditions. It is also at this meeting that each participating organisation shares its improvement programmes, as one organisation may be planning to take action that could impact on the others.’

The programme board has been driving through its long-term conditions programme with planned savings for 2013/14 of £4m.

Mr Melling says the planned £4m saving was included in the 2013/14 contract negotiation process, which led to a reduction in the acute contract. The objective is to improve the quality and effectiveness of care for people with multiple long-term conditions, achieved in part through improved self-care and shared decision-making.

Integrated neighbourhood teams are being introduced throughout the health economy to care for people with multiple morbidities.

Smaller initiatives

Wigan Borough CCG also has a number of smaller projects. For example, high-street opticians have said they can carry out some post-operative work usually done by ophthalmologists in the hospital. These include final outpatient checks for patients who have had cataract operations, making the process more convenient for the patient.

Mr Melling says Wigan wished to move a number of services out of the hospital setting and into the community. ‘Wigan has developed a model for the risk stratification of patients – identifying those who can be managed more effectively in a community setting,’ he says.

Bridgewater Community Healthcare NHS Trust is moving this forward using integrated neighbourhood teams. The programme plans to reduce the number of non-elective admissions by 20% and reduce the length of stay for the same cohort by 25%.

North Hampshire Clinical Commissioning Group is also using risk stratification to identify patients likely to be heavy users of healthcare services, including those with long-term conditions, and then supporting them to keep them out of hospital. This is supported by six locality-based integrated care teams. They are GP-led and include Hampshire County Council social care and Southern Health NHS Foundation Trust community staff.

Chief finance officer Pam Hobbs says the CCG has a significant efficiency challenge of 4.1% (about £9m) this year. About £3.9m of this relates to planned savings at the acute trust. There are a number of differences in the approach to QIPP, including a greater local focus – avoiding the one-size-fits-all approach that was sometimes adopted in the past.

There is more clinical engagement than ever before, with up to 30 GPs working on projects or leading initiatives for the CCG.

‘Most of the projects we are running have been aspirations for the local clinicians for a long time, and now that we have the CCG, they want to move quickly,’ says Ms Hobbs. ‘In my experience, the only true transformation comes from clinician to clinician discussion.’

The CCG is also working on the front end redesign of the local accident and emergency departments. Local GPs from the out-of-hours provider will be placed in each A&E from October or November.

‘Our belief is we should be able to deliver quality improvements and savings at the same time. If people don't need to be admitted, there’s a benefit in terms of quality and we are able to achieve a reduction in the amount we pay,’ says Ms Hobbs. ‘GPs will be encouraged to make sure they refer the patients back to their own GP so they don't keep turning up at A&E.’

A Nuffield Trust report in 2011, Setting priorities in health, said PCTs focused their attention on new and marginal spending each year and rarely reviewed whether all their existing spending was appropriate.

With the need to release funds for reinvestment, it is unlikely that CCGs will be able to continue in this vein. Some are already undertaking a root-and-branch review of their commissioning expenditure. This includes the Stoke and North Staffordshire CCGs.

‘We are taking a hard look at everything we spend in both CCGs,’ says Mr Matthews. ‘We are looking at where we can go in terms of securing those efficiencies.’

Beyond the figures

This baseline review is nuanced, he says. The CCGs are looking beyond the figures at the unintentional consequences that cuts could have on services to patients.

‘In the old days, we might have looked at cutting something like voluntary sector funding, but we would be cutting off our nose to spite our face because we know, in the main, that they provide a really good service that helps keep people out of hospital,’ adds Mr Matthews.

These ‘whole baseline’ reviews must be more sophisticated than this and connect with the rest of the commissioning agenda, he believes.

‘I have the sense that we are having the right conversations,’ Mr Matthews continues. ‘We are not far down the line, but we have to get into this quickly. Our next planning round – for 2014/15 – will be pivotal and our GPs continue to lead the process.’

It has been reported that nine CCGs plan to make a deficit in 2013/14. They forecast an aggregate deficit of almost £87m in their first year in operation, some due to legacy financial difficulties, others because of adjustments to specialist commissioning budgets, resulting in transfers out of their allocations.

Some commentators believe the financial pressure on CCGs will throw up difficult – and for some GPs, unpalatable – decisions. Many GPs are known to be uneasy over whether decisions taken as a CCG will affect their relationships with patients.

CCGs are just beginning their QIPP journeys. Clinicians are in the driving seat, but the road ahead could be bumpy.