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Concerns raised over Clinical Commissioning Groups

The draft guidance on developing commissioning support to Clinical Commissioning Groups (CCGs) raises many concerns within the UK Faculty of Public Health (FPH). These fall into three broad categories:

  • The impact on the health of the population.
  • The impact on the NHS.
  • The impact on the health of the people.
The impact on health

People's health and wellbeing is of primary concern to FPH. FPH believes that "the separation of commissioning decisions about populations and the support functions" will be bad for people’s health. It will lead to fragmentation of the commissioning function and a diminution of the ability to develop coherent local policies, both of which may result in essential health services not being developed effectively - or efficiently - to meet people's needs. Disadvantaged and hard-to-reach groups may become further marginalised. It is also likely to increase the postcode lottery in commissioning, resulting in wide variations between similar communities in the services available to meet local health and wellbeing needs. It makes no sense at a time when increasing health needs and reducing finances pose huge challenges for services. What is urgently needed is close collaboration between local organisations, integrated commissioning across health and social care and efficient services which meet local needs. The proposals described in this document are more likely to result in disintegration and waste.

The impact on the NHS

This paper removes any doubt that the intention of the bill is to move commissioning support out of the NHS. This is made abundantly clear from page 19 onwards. FPH considers that this is a high-risk strategy for patients, the public and the NHS, especially in these times of financial challenge. Commissioning must be able to develop integrated care pathways, based on a profound understanding of local needs and contexts, that will deliver maximum health gain for each pound spent.

The ability to achieve this is a core public health skill, which must be harnessed for the benefit of patients, the public and the NHS. It cannot be delivered in a fragmented way. The model in the paper could result in local commissioners receiving different and potentially conflicting advice from a range of organisations, each with a different primary focus. The potential for conflicts of interest is obvious. These arrangements are likely to result in an incoherent and commercialised market for commissioners managing an incoherent and commercialised market for provision. The government and the taxpayer cannot be assured in such a system that they are receiving either value for money or the comprehensive services the NHS is required to provide.

The impact on good public health practice

The document sidelines and downplays the integral role that public health plays in the commissioning of NHS care and services. It gives the impression that public health is simply about giving 'strategic' advice, whereas the reality is that public health plays an active role in every level of the commissioning process. Statements that imply that there will be different, uncoordinated  sources for 'advice and support' for CCGs which may come from Public Health England, public health in local authorities and commissioning support functions are of particular concern. This will defeat the objective of integrated commissioning for care pathways, and will lead rapidly to fragmented commissioning.  The "detailed analysis of referrals and activity" is a core public health function, requiring understanding of the reasons for referral, the possible consequences of changing pathways and the implications for clinical systems. All need to be analysed and balanced to ensure the best possible health outcome for patients and the public within the available resources. Splitting the 'commissioning support supply chain' in this way will have a serious, negative impact on effective and coherent commissioning. It will not be in the best interests of patients or the public.

Written: 07/12/2011 , last modified: 06/02/2012