Building bridges

Michael Sobanja
Chief Executive, NHS Alliance

Clinical commissioning groups (CCGs) are about to come in to being as a result of the Health and Social Care Bill 2011, which will become an Act in early 2012. It will cement the way for the beginning of widespread changes in the NHS, which of course have already begun.

Michael Sobanja
Chief Executive, NHS Alliance

At the heart of these changes CCGs are new statutory bodies, which will take most of the responsibilities that rested previously with primary care trusts (PCTs). I say most, because it is important to recognise that PCT functions will be divided, with some going to local authorities, some to the NHS Commissioning Board (NCB) itself, and the rest to CCGs. In reality, this means that CCGs will take on about two-thirds of the responsibilities of PCTs defined in financial terms. This article looks at the need to establish communications and relationships at three levels: first, patients and populations; second, with health partners locally; and third, with the NCB and its hosted groups.

Clearly, establishing good communication and relationships will be of vital importance. But equally, being clear about purpose is a prime requirement. In my view, CCGs’ main task is to improve the health of local populations, not simply organise effective and efficient healthcare. We know that the factors that affect health status are much wider than healthcare alone and include lifestyles, education, housing employment and so on. Only through leading and influencing the wider determinants of health will CCGs achieve their central purpose.

Patients and local communities
Whose NHS is it anyway? This is the title given to a document developed by the NHS Alliance with support from a wide range of organisations, including Arthritis Care, National Voices, the National Association for Patient Participation (NAPP), the Patient Information Forum (PiF), the African HIV Policy Network (AHPN), Diabetes UK and the National Association of LINKs members (NALM). It argues that patients need to be involved in their care and that local people and communities should be involved in the planning of their local NHS. However, the evidence shows that:

Patients want more involvement in their care than they currently have.
There is growing evidence that greater patient involvement has a positive impact on health outcomes, quality of experience and value for money.
The NHS still struggles to listen and to respond to user opinion.
Commissioners and clinicians, despite getting better at knowing what people want, find it hard to respond to local needs.
Paternalistic attitudes persist, particularly in the way clinicians deal with patients.
We are only beginning to consider how to maximise the benefits of community involvement in health.
Better community engagement is likely to be a key ingredient in putting greater emphasis on prevention and healthy living.

This is a key role for CCGs – both ensuring that patients are partners in their healthcare, but also that citizens are partners in population health improvement. Developing effective communications in this area will be important, not only in creating engagement but also in providing the CCG with legitimacy given the tough decisions in recognising the demographic demands and the financial challenges we face now and in the future. CCGs will need to find ways of encouraging self-responsibility, supported self-care and the appropriate use of heathcare resources, as well as organising integrated healthcare delivery.

Local authorities and Health and Wellbeing Boards
The notion of population health improvement also requires the building of partnerships across stakeholders and organisations at a local level. The focus for this work is likely to be local authorities and through Health and Wellbeing Boards (HWBs) hosted by them.

On any given day, there are some 8,000 emergency admissions to hospital each day in England. Of these, a large proportion will result from respiratory disease. While healthcare has a key role to play in minimising these, wider action is needed – for instance, in improving damp in social housing, taking action on education and so on.

The HWBs are the nexus for this work and should bring together not only health and local authorities, but also local employers, the justice system, and other key players. In this sense, CCGs must be key partners but also be recognised as local leaders in health improvement, working with and through other agencies.

This work has its roots in the Drugs Actions Teams of the 1980s, which brought together key players to take forward broad programmes of work in substance misuse, and gave health bodies a focus outside of healthcare. An example would be the establishment of court diversion schemes aimed at avoiding people with heath problems falling unnecessarily and inappropriately into the penal system.

Working with local authorities also has a different dimension. The way in which local authorities work is set to change dramatically with the passage of the Localism Bill, which has recently received royal assent. It foresees more local decisions, through local government, which will become public-sector investment organisations. The early pilot work in Cornwall gives us some indication as to the future and the need for cross-sector working, which must have health as a key building block. Health cannot stand outside of this, and while the Health and Social Care Bill has taken centre stage this year, the Localism Bill is of equal importance going forward.

I would contend that local government has also often been more effective than the health sector in engaging citizens and communities in their work. It is important that CCGs build and join in this type of approach, and build upon the approach taken with regard to, for instance, mental health, deprived communities and minority groups. We don’t need to reinvent the wheel!

This is challenging and difficult work, which requires both sound communication and relationships that are mutually supportive. Seeing local services, including health, as an investment that must give a return on health improvement, requires a more fundamental shift in the way that all public bodies undertake their work.

CCGs must also develop healthy relationships with the NCB, which will of course take a leading role in national direction, priority setting, resource allocation and performance management, but must essentially be supportive of CCGs in population health improvement, not falling into the trap of telling them what to do and how to do it. This requires a significant change in the behaviour of both the central and local organisations, to establish partnership and mutually supportive relationships rather than hierarchical ones. This needs a different approach than that taken in the past, for instance, between the Department of Health and PCTs, which has often had more of a flavour of a parent-child relationship, than one of mutual support.

The NCB will commission services directly – both specialist services and general medical services for local people. With regard to the latter, we know that the NCB will hold the contracts for general practices, community pharmacy, opticians and dentists. With regard to specialist services, this of course does not exist in a vacuum, in the sense that every patient who benefits from a specialist service also is a user of local services at the same time. Both specialist services and local services are integrated in a far more coherent manner than has been the case in the past. Indeed, it could be argued that the NCB, in commissioning specialist services, is doing so as an agent of CCGs, who retain the ultimate responsibility for local health.

The NCB’s role in commissioning and holding general medical services contracts is both understandable and challenging. CCGs have a key role in not only commissioning but also leading a collective approach to health improvement, which should involve all services with a view to generating integration.

Integration of service delivery is not just a matter of joining up primary and secondary or even tertiary care (vertical integration) but requires joining up services across primary and community-based services (horizontal integration). In both dimensions, the communications and relationships between CCGs, the NCB and other bodies, such as clinical networks and clinical senates, will be key.

While we know relatively little about the detail of how these bodies will operate in the future, they will be hosted by the NCB and should exist to support the work of CCGs. There is a considerable argument, therefore, that the focus on population health improvement requires that CCGs take a central role in bringing all of these functions together.

The relationship between the CCGs, the NCB and these other bodies will, therefore, not be linear; in some cases, it will be the centre taking the lead – for instance, in setting national priorities.

In other respects it will be part of a mutually supportive partnership, perhaps in commissioning primary care, and in another form, CCGs will take the lead with the NCB securing clinical services that integrate with local plans. CCGs must learn, along with the NCB, how to establish relationships with multiple strands and not just accept a transfer of the hierarchy of the past with new names.

CCGs must be at the heart of the system, with a clear focus on population health improvement. To achieve this they need to establish both communication and relationships with patients, the populations they serve, local partners in health, and create a new relationship with the centre. In short, CCGs must be the catalyst that changes not only the structure of the NHS, but also its culture and behaviour. Liberating the NHS was not intended to simply be yet another reorganisaton; its success will depend on the culture and behaviour of those who work within it, not a changed structure.