The King's Fund has set out 10 priorities for commissioners to transform the healthcare system in England within the new NHS landscape which began on April 1.

211 clinical commissioning groups (CCGs) are now responsible for most of the NHS budget - over £65 billion for secondary care and community services. At the same time, public health budgets of £2.7 billion are transferring to 152 local authorities, while NHS England (formerly the NHS Commissioning Board), through its 27 area teams, takes responsibility for commissioning primary care (£13 billion) and specialised services (£12 billion).

Collectively, the task of this new set of commissioners is to deliver a sustainable health care system in the face of one of the most challenging financial and organisations environments the NHS has ever experienced, says the health policy think tank.

"The task is especially daunting in the context of a population in which the burden of disease is growing and medical advances offer increasing opportunities to treat disease, but at a cost. The result, if nothing else changes in the NHS, will be significant unmet need and threats to the quality of care," it warns.

The Fund’s 10 priorities for action by commissioners are:

- active support for self-management: this can be viewed as a portfolio of techniques and tools to help patients choose healthy behaviours and also a fundamental transformation of the patient-caregiver relationship into a collaborative partnership;

- primary prevention: taking action to reduce the incidence of disease and health problems within the population, either through universal measures that reduce lifestyle risks and their causes or by targeting high-risk groups;

- secondary prevention: systematically detecting the early stages of disease and intervening before full symptoms develop - for example, prescribing statins to reduce cholesterol and taking measures to reduce high blood pressure;

- managing ambulatory care-sensitive conditions (ACS): for these chronic conditions – which include congestive heart failure, diabetes, asthma, angina, epilepsy and hypertension - acute exacerbations can be prevented and the need for hospital admission reduced through: - active management, such as vaccination; - better self-management, disease management or care management; or - lifestyle interventions;

- improving the management of patients with both mental and physical health needs with a more integrated response, in particular supporting people with common mental health problems such as depression or anxiety alongside a physical long-term condition;

- care co-ordination through integrated health and social care teams: creating patient-centred care that is more coordinated across care settings and over time, particularly for patients with long-term chronic and medically complex conditions who may find it difficult to navigate fragmented health care systems;

- improving primary care management of end-of-life care: particularly coordination of care, continuity, quality of communication and the provision of bereavement care;

- medicines management, which supports better and more cost-effective prescribing in primary care, as well as helping patients manage their medications better. Good medicines management can help to reduce the likelihood of medication errors and, therefore, patient harm;

- managing elective activity-referral quality: managing planned hospital activity by systematically reviewing and auditing referrals, with a view to benchmarking against other practices and improving referral quality, and by ensuring patients are fully involved in decision-making; and

- managing urgent and emergency activity: developing an integrated approach to urgent and emergency care - particularly emergency medical admissions to hospital - involving hospital, community, primary and ambulance services through joint service planning and sharing of clinical information across different agencies.

The Fund authors point out that a notable feature of these 10 priorities is the degree to which they call for change within primary care and the way in which primary care relates to the rest of the system.

They also note several common themes across the priorities. It is clear, they say, that commissioners need to help drive:
- more systematic and proactive management of chronic disease: this will improve health outcomes, reduce inappropriate use of hospitals and have a significant impact on health inequalities;
- empowerment of patients - arguably the greatest untapped resource within the NHS;
- a population-based approach to commissioning: a key challenge for commissioners is to direct resources to the patients with greatest need and reverse the "inverse care law." Clinicians involved in CCGs will need to shift their focus from the patients that present most frequently in their practice to the wider population which they now serve; and
- more integrated models of care, from virtual integration through shared protocols to integrated teams and, in some cases, shared budgets and organisational integration.