Tuesday 11 February 2014

What can clinical commissioning groups learn from Oxfordshire?

What can clinical commissioning groups learn from Oxfordshire? Oxfordshire CCG's experience demonstrates that although commissioners control the finances, providers are still in charge.

The unravelling of the plans by Oxfordshire clinical commissioning group to introduce outcomes-based service contracts shows that while commissioners have the money, providers are still running the system. What will it take to break their power?


Oxford health foundation trust and Oxford University hospitals trust's forceful objections to plans for outcomes-based commissioning of adult mental health, maternity and older people's services included the fact that the changes would introduce new financial and clinical risks and affect the local health workforce. But they supported the overall aims, of course.

Tell any discussion on public service reform that the public sector needs a new attitude to risk, and you can be sure that your comment will be greeted with vigorous nods. But commissioners and providers need to turn those sentiments into action. If introducing new risks is going to be an acceptable reason for torpedoing reform proposals, then we will remain lumbered with the old risks of running out of money while fitting our patients into services instead of building services round patients.

Disrupting the health workforce in securing change isn't just a risk – it is essential. New patterns of care will create winners and losers among staff.

A gateway review of Oxfordshire's proposals by the Department of Health in light of the providers' objections has more than a whiff of political expediency. Drinking deep from the well of civil service clichés, it concludes that the CCG should see 2014-15 as "a transition year" with a "need to review the scale and range of services". All this should be done "having carefully thought through all the implications". And of course it calls for piloting.

Tellingly, the review recommends involving the current providers in designing the new services. While this may well be the right approach on many occasions, it should surely be up to commissioners to decide whether it is in the best interests of patients. If, for example, a CCG believes an incumbent does not have the vision or skills to develop a new type of service, surely it should have the discretion to pursue a different route.

So the DH talks tough about improving the patient experience, focusing on outcomes and using competition to bring about change, but when it comes to politically contentious decisions – especially ones affecting the prime minister's constituency – it runs away.

The unravelling of the Oxfordshire plans is likely to be seen as a victory for inertia. It gives the message to trusts that if they resist hard the DH and commissioners are likely to back down. It also reinforces the belief that despite the health reforms rebuilding the entire NHS around a commissioning system, the power of providers is undiminished. A mere act of parliament is no match for them.

CCGs could easily take away the lesson that ambitious changes such as challenging incumbent providers and commissioning for outcomes will fail, and that they should opt instead for incremental change.

But if that happens, clinical commissioners will have demonstrated that they are incapable of reforming the health service. Instead they should learn from Oxfordshire's experience about how to prepare the ground for change.

It is clear from divisions in Oxfordshire CCG's own ranks that it could have made a better job of building a coalition of support for its radical plans. Contracting is only a powerful tool for large-scale change if it is accompanied by convincing clinical evidence and political support.

Many providers and CCGs are beginning to develop strong and trusting relationships, on which they are building a shared vision of the need to change. But where the relationship is less constructive, CCGs simply do not have the clout to batter through change in the face of concerted opposition. If pushing through change involves having a scrap with the incumbent provider it will require political guile, and lots of it. Commissioners cannot allow providers to be seen as having the exclusive right to represent patients' interests. Guardian Professional.

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