Nurses have a vital role to play in commissioning but need support as they take on these developing responsibilities to counter competing demands on their time
This article explores the changing landscape of commissioning, the commissioning nurse role within clinical commissioning groups (CCGs) and how the role has evolved as a result of the NHS organisational changes. It uses the results from two surveys undertaken by the Commissioning Nurse Leaders network, run by NHS England, to gauge the confidence of nurses in commissioning and leadership roles.
Citation: McCann S et al (2014) Role of the CCG nurse in commissioning services. Nursing Times; 110: 48, 15-17.
Authors: Stacey McCann is commissioning lead nurse, NHS England; Anne-Maria Olphert is chief nurse director of quality Erewash CCG; Virginia Minogue is research lead, medical directorate, NHS England.
- This article has been double-blind peer reviewed
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Until recently nurses have not traditionally been involved in commissioning services. That changed in 2012 when clinical commissioning groups (CCGs) were established, along with statutory roles for nurse leaders within these groups. This put nurses in an influential role where their expert opinion is communicated to the wider clinical team and the competencies of individual nurses are used as strengths within the CCG, particularly around quality assurance of services.
Nurses in commissioning
At an individual level nurses are instrumental in planning and delivering patient care. They assess patient needs, plan and deliver care as efficiently as possible and then evaluate the care given. This process is fundamentally the same as the commissioning process, but in commissioning the planning of services or care is based on the needs of a local population rather than an individual. Commissioning includes assessing population need, planning and delivery of services and evaluating outcomes.
Nurses have historically viewed commissioning as something undertaken by health service managers. It is underpinned by health service budgets, contracts, procurement processes and meeting targets; all processes that in the past seemed to have no impact on frontline nurses - but things are changing.
As a result of the changing NHS landscape the commissioning process is moving into the hands of patients and clinicians. The aim is to engage them in making sure health resources are used as effectively as possible to meet local needs.
As NHS policy continues to travel in this direction, nurses in all spheres of the profession have an opportunity and a responsibility to become involved and influence commissioning decisions. For some this may feel removed from their everyday activities on the ward or out in the community. However, every nursing action undertaken when caring for a patient is influencing and affecting the commissioning process, whether that is ensuring care is of a high quality or by planning new patient pathways.
Clinical commissioning groups
An important part of the NHS reorganisation saw the establishment of CCGs, in which nurses were given key appointments. It was mandated as part of the statutory regulations of the Health and Social Care Act (2012) that they would be part of the governing body and for the first time nurses were given a key influential role at a senior level in the commissioning process.
The value of having an experienced nurse at a senior level within a CCG means that issues of care, compassion, dignity, quality and safety can be embedded in the commissioning process. Nursing represents the largest professional workforce in the UK, so the senior leadership within provider organisations should be matched by senior nurse leaders within every part of the commissioning landscape (NHS Commissioning Board, 2012). CCGs need to ensure that they have the ability to develop relationships with a range of professionals, including senior nurses in all parts of the healthcare system. This requires a credible leader with vision, presence and a senior profile to lead and respond to issues across health and social care settings.
The commissioning nurse in a CCG works with nurses in a variety of settings across the healthcare system to make sure services delivered for their populations are safe and of a high quality. Nurses who are not directly involved in commissioning help develop patient pathways that make sense to patients and meet their needs in a compassionate and caring way.
Compassion in Practice, the three-year vision and strategy for nursing, midwifery and care staff was launched in December 2012, and gave nurses even more opportunity to influence commissioning decisions, with a view to improving standards of care for populations and improving outcomes in healthcare overall (NHS Commissioning Board, 2012a).
In 2012, Jane Cummings, chief nursing officer for England, highlighted the struggle to get nurse representation onto CCGs. She wanted to bring together the experiences of nurses involved in commissioning to help to make the concept of “clinical commissioning” inclusive of nurses and other health professionals (NHS Commissioning Board, 2012b). In May 2013 NHS England responded by partnering with the Royal College of Nursing to develop the first national network for nurses who commission NHS healthcare in England - the Commissioning Nurse Leaders network. All commissioning nurses from CCGs and commissioning support units, as well as regional and area teams within NHS England, were invited to join. Today the network has 415 members and is the only national network for these nurses that covers the whole commissioning system for commissioning nurse leaders. The four main objectives of the network are to:
- Support commissioning nurses as system leaders, to fulfil their leadership potential;
- Provide a support network to maximise their clinical and professional contribution in ensuring high-quality, safe care;
- Provide effective communication responding to commissioning nurses’ requests for a network;
- Enable commissioning nurses to engage with the wider commissioning system and agenda.
Over the past 18 months the network has supported members by providing a variety of communication routes and a number of face-to-face nationwide events that have focused on the nurses’ shared purpose as commissioning leaders. They have also provided a safe space for CCG nurses to share their experiences and explore shared solutions to common challenges.
The network has been hugely successful in engaging nurses from a commissioning perspective to enable a greater nursing input into shaping and delivering services for local populations that are safe, high-quality and effective. It has been the conduit to link commissioning nurses who want to become involved nationally in projects such as the Transforming Nursing for Primary and Community Care Strategy (NHS England, 2014a).
Part of the network’s success has been its ability to link commissioning nurses with colleagues in similar CCG areas; this has resulted in a buddying system evolving between network members.
Survey of CCG nurses
Survey aim and method
To measure the success of the network in supporting and developing the role of CCG nurses, an online baseline questionnaire was sent out in July 2013 to 120 commissioning nurses in CCGs across England. Three reminders were sent and 79 nurses responded, giving a response rate of 66%. Access to commissioning nurses was through the CNL network database, which is information governance-compliant. Informed consent was obtained from all network members, explaining the type of data held and how the stored data would be used and shared if appropriate. The questionnaire was repeated 10 months later, in May 2014, when 168 CCG nurses across England were asked to take part. Sixty-nine responded, giving a response rate of 41%.
The purpose of the two questionnaires was to assess respondents’ self-reported levels of confidence and competence in commissioning and leadership skills, and to assess the changes that had occurred over the year. The questionnaires also provided evidence of the key challenges and issues faced by senior commissioning nurse leaders.
Findings and discussion
The two surveys have demonstrated an increase in the confidence of commissioning nurses in terms of their commissioning and leadership skills. The results of the 2014 survey show a rise in confidence levels from 2013 (NHS England, 2014b; NHS Clinical Soft Intelligence Service, 2013). This is illustrated in Fig 1.
Commissioning nurse leaders need a level of experience of leadership and strategic thinking, and so have been recruited in the main from existing senior nurses. This means they are relatively mature, predominantly female and white British. This situation requires careful succession planning to ensure that the demographic of commissioning nurse leaders becomes more representative of the nursing workforce and of the populations that local CCGs serve in the future. There is a need to engage the wider nursing workforce to promote commissioning as a possible future career, one which nurses may not currently consider.
Nurses bring a wide range of skills to the commissioning process. These include leadership, knowledge of the quality agenda, safeguarding and governance, skills in relationship building and an understanding of the patient perspective. The survey results (NHS England, 2014b; NHS Clinical Soft Intelligence Service, 2013) show that commissioning nurses feel they have high confidence and competence in their commissioning and leadership skills, which for this group of nurses often stems from their former roles as senior nurses in NHS organisations. Challenges were identified that sometimes created a lack of confidence; these included lack of time, emerging new roles and competing demands on their time and role, as well as concerns about their ability to influence and provide leadership. Providing leadership in the new environment of CCGs can be a challenge for nurses, but 95% rated themselves highly in their confidence and competence in the role.
The responsibility for quality and safety is a key role for commissioning nurses - as much as it is for any nurse in the profession. Following high-profile cases, such as the failings in Mid Staffordshire and Winterbourne View, commissioning nurses are playing an important role in ensuring the quality and safety of commissioned services in CCGs. Of the survey respondents, 84% reported feeling confident or fairly confident in their ability to lead the quality assurance agenda. Supporting them to achieve this goal is the Compassion in Practice strategy, which many commissioning nurses draw on to influence other CCG members (NHS England, 2014b). However, there is a strong feeling among commissioning nurses that quality is not just a role or concern for nurses, but should be the responsibility of all clinicians.
Further analysis of qualitative data from CCG nurses (NHS England, 2014b) identified the five most challenging issues they still faced. These are:
- Complexity and breadth of role, less funding and lack of time;
- Relationships with commissioning support unit colleagues;
- Striving for the best possible quality of care for their populations;
- Managing regulation in a complex system;
- Continuing healthcare management for patients who have have a complex medical condition and substantial and ongoing care needs.
The network is part of the continuing commissioning support that NHS England, and particularly the chief nursing officer’s directorate, will offer to commissioning nurses, in order to secure “high-quality care for all now and for the future” (NHS England, 2014c). It will continue to provide commissioning support while working with other partner organisations such as Health Education England, Public Health England, The Royal College of Nursing and the Department of Health. In doing this the network aims to reduce duplication of effort and build on collaborative working.
Developing the commissioning nurse role
Nurses in CCGs bring a wealth of clinical and local knowledge to commissioning, and a breadth of experience that allows them to champion the patient experience at both an individual and population level. These skills are not exclusive to commissioning nurses - all nurses have them, they practise them on a daily basis, caring for individuals and championing their patients’ needs. The nursing profession needs to recognise the value that nurses can bring to the commissioning system and nurture future commissioning nurse leaders.
The experience of some commissioning nurses means they can find themselves working outside their traditional sphere of professional practice when commissioning for outcomes, using creative problem solving and risk management strategies based on professional experience, intuition and understanding. Their focus will be local populations at the centre of the new commissioning system - their needs, their priorities, and their involvement in all healthcare decisions.
Commissioning for populations while working within the resources of the health service will add pressure to the commissioning nurse role, especially when new developments such as primary care co-commissioning (NHS England, 2014d), new Care Quality Commission regulations (tinyurl.com/GPinspect), and the continuing healthcare and personal health budget (NHS England, 2014e) are introduced.
Commissioning is becoming everyone’s business. As NHS changes continue to take effect, nurses in all walks of the profession are finding themselves better placed to offer challenge and influence in the commissioning system. In particular, commissioning nurse roles have developed during a time of great change and challenge. There has been organisational change and new ways of working in the NHS and extensive criticism by the media of the nursing profession following the Francis inquiry (Francis, 2013).
There is a need for all nurses to take responsibility to improve quality of care. The challenge is how we inspire all nurses to become role models. It is increasingly important to involve operational nurses in commissioning, and the champions of change are the commissioning nurse leaders in CCGs who are responsible for being role models to nurses across the profession. It is clear from the surveys undertaken by the CNL network that commissioning nurses are committed to their roles in CCGs and are striving to deliver on quality assurance and commissioning high-quality care for their populations.
- Commissioning nurse leaders are statutory roles in clinical commissioning groups (CCGs)
- Nurses need to be able to influence the commissioning process
- Commissioning CCG nurses bring a wealth of clinical knowledge to the role
- These nurses help to ensure high-quality and safe services
- Support for nurses in this developing role is available from the Commissioning Nurse Leaders network
Francis R (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: Stationery Office.
NHS Clinical Soft Intelligence Service (2013) Confidence in commissioning; CCG nurses. (Internal report: unpublished)
NHS Commissioning Board (2012a) Compassion in Practice, Nursing, Midwifery and Care Staff, Our Vision and Strategy.
NHS Commissioning Board (2012b) The Importance of Nurse Leadership in Securing Quality, Safety and Patient Experience in CCGs.
NHS England (2014a) 6Cs live communication hub. Transforming Nursing for Community and Primary Care.
NHS England (2014b) CNL Network survey results. (Internal report: unpublished)
NHS England (2014c) Putting Patients First: Business Plan 2014/15 - 2016/17.
NHS England (2014d) Primary Care Co-Commissioining. Board paper NHS071405
NHS England (2014e) Guidance on the “Right to Have” a Personal Health Budget in Adult NHS Continuing Healthcare and Children and Young People’s Continuing Care.