Monthly Digest September 2014

6 new posts have been published on my ‘Inside Health’ column on since the last digest. You can find them here.

Commissioning Support Units Framework: Help or hindrance? – is the forthcoming procurement of commissioning support units (CSUs) likely to be a distraction from the real task which is an improvement in CCG/CSU relationships?

Nice – ‘The Jewel in the NHS crown’ – NICE has to make difficult decisions because there is not enough money in the NHS, and it plays a critical role in making sure we make the most of the money we have. Are we giving it the credit it deserves?

Clinical Commissioning and the NHS Internal Market – Like it or loathe it the NHS has an internal market, and it is the job of CCGs to make this market work in the best interest of patients and taxpayers.

Rationalising Notional Rent Essential to Solving GP Shortage – Lack of decision making about notional rent is stopping the development of general practice dead in its tracks.  Co-commissioning must prioritise unlocking this issue.

GP Conflicts of Interest must be managed and be seen to be managed – Failure to provide real and visible management of GP conflicts of interest following the introduction of co-commissioning could lead to a loss of public confidence in CCGs.

Collaboration in the NHS is more difficult than ever before – the introduction of a plethora of regulators and the minefield of competition regulations means that it is harder than ever before for NHS organisations to collaborate effectively.

Let me know what you think!  You can contact me here, via website or on twitter @ccginsider.


As some of you are doubtless aware, I have been bemoaning the lack of an NHS podcast for some time.  In the end I was challenged to do something about it, and now (albeit 6 months later!) the first podcast is out.

I am working with Joe Tibbets who is a commentator on the public sector, and who has been bemused by the NHS for a long time.  We are going to have a series of conversations to try and make sense of some of aspects of the NHS, which to the outsider looking in must seem very complex indeed.  Joe has been pretty gentle on me so far, but I suspect he will get tougher as time goes on!

In the first one we have touched on GP conflicts of interest, and had an interesting debate about NICE and its role in a cash-strapped NHS.  The podcast is called Reality Bites, and you can find it by clicking on the link below:

Please let me know what you think.  You can either leave a comment here, on the information daily site, or via twitter where I am @ccginsider.  I am sure it can get much better, and the more you let me know how, the quicker we will get there!

Thanks again for all your support



Since last time there are 4 new posts, all published on (here):

What is co-commissioning?  – which looks at how in a short space of time co-commissioning of primary care seemed to evolve from delegated budgets to partnership working between CCGs and NHS England.

Out of hours healthcare provision in need of urgent treatment – which suggests that with development of 111, extended primary care hours, and GP streams in A&E departments, the role of out of hours needs to be urgently reviewed.

The Lost Art of Clinical Commissioning – which says that because of procurement processes CCGs are losing their focus on inspiring and empowering clinicians from all specialties to come together to make change happen

Is the Better Care Fund preventing integration rather than promoting it? – concerns about the shift of money from health to social care, evidence about the lack of impact of integrating health and social care commissioning functions, and an overly bureaucratic process mean the potential gains of integration could be lost.

As always, any feedback gratefully received!  You can follow me on twitter @ccginsider, leave a comment here, or leave a comment on


The Next Phase

Hello all!  Thanks for all the messages of support since my last post at the end of February, where I asked the question as to what next for the website.  Many of you contacted me directly with a number of suggestions, and many gave direct offers of help, and I really appreciate all of your input.

In the end I have decided to continue the blog with support from those with more technical capability than myself!  As a result the blog will now be hosted by The Information Daily ( ), which will provide a much better platform for both hosting and disseminating the content more widely.

Just for the record I still do not receive any form of payment or income for the blog, which is, and always has been, designed to support those working in and with health.

The first of the posts on the new platform is now live, and you can access it by clicking here.  It is entitled, ‘NHS cannot transform healthcare while defending the status quo’, and I argue that radical change may need to come from outside the NHS.

For the next few months I will post a message as a prompt that the new weekly blog is out.  Thank you for your continued support, and do let me know ( if you have any specific questions or topics you would like me to cover.




I set up at the start of 2012.  Since then I have posted every week for over two years about CCGs and all the issues that they have faced in setting up and getting established.  There are now 110 articles on the site, covering issues ranging from making commissioning support effective to the future of general practice. 

The information on the website is provided completely free of charge.  There are hundreds of subscribers to the site receiving the weekly blog.  The most popular articles are (surprisingly) the ones on estates and NHS Property Services! 

The site has offered support to CCGs in the year before they were formally established and in their first year with the new responsibilities.   As we now approach the completion of this first year of CCGs as statutory bodies it is time for a review of the site.  Over the course of the next month I will be considering the following options, and with this I would really value your help.

As I see it there are 6 possible ways forward:

  1. No change.  I could continue to produce a weekly blog as I do now and adapt the content to the changing needs of CCGs as they evolve into the future.
  2. Adapt the existing site.  I could continue with the current site, but adapt the content, format, style so that it better meets your needs.  For this you will need to tell me how you would want it to change.
  3. Start a totally new blog/website.  I could draw a line under the period of the establishment of CCGs, and leave as it is without adding any further content.  I could set up a new blog or website and focus on a new or different area. 
  4. Start a podcast.  As far as I can tell there is no regular podcast within the NHS at present.  As podcasts grow in popularity there must be a place for one within the NHS.  I have no idea how to set one up, but could set about finding out!
  5. Work with others. I have largely produced the content for on my own.  For any of options 2, 3 or 4 above I could work with any interested individuals to make them happen with a wider range of input (let me know if you are interested!).
  6. Stop altogether.  I could of course draw a line under the work to date, recognise the value that it has added so far, but stop and focus on other things.

As I carry out the review over the next month, I would really value your input.  It would really help me if you could let me know what you find valuable about the site, what does not work very well, and what you think of the options outlined above as regards a way forward.  Please email me on to let me know your thoughts. 

Just to be clear this means that there will be no posts for the next month.  Before the end of March once the review is completed I will update on the way forward.  I look forward to hearing from you in the mean time, and thanks in advance for your help!


The closest I have been to death was a few years ago when I was playing golf in France.  I remember the day vividly.  It was a bright, sunny Sunday morning, but the weather was very much in contrast to the way the three of us were feeling, as we struggled to recover from two nights over-indulging in the local red wine.

After the usual frenetic battle to get to the course on time (missed alarm call, rapid check out, the impossible task of finding a golf course in a foreign country armed with only an out of date map and a singular lack of helpful signposting), we finally arrived at the first tee.  But we needn’t have rushed, as the queue was three groups deep, and it was the best part of half an hour before we were on our way.  Our frustration grew.

Even when we got going the pace didn’t pick up.  We had to wait to play every shot, which meant we also got to watch the group in front.  There were two men and a lady, all of whom were French.  The second hole was a par three.  One of the men and the woman hit reasonable tee shots; the second man hit two tee shots into the deep rough, and rather than play a third just picked up his tee and trudged towards the green.  I know the feeling.

When we got to the third tee, the group ahead had already teed off and were in the fairway waiting to play their next shot.  Then all of a sudden one of the men fell to the ground.  He didn’t get up.  We just stood there, staring, not sure what was going on.  Our trance was broken when all of a sudden the woman started haring towards us, screaming in French at the top of her voice.

As she came towards us, I asked if any of us knew CPR.  None of us did.  We weren’t even sure what it stood for (this was before we had the ‘Staying Alive’ adverts, so we didn’t even have that to guide us!).  However, one of my group did speak reasonable French, so we agreed he would ring for an ambulance and then ring the clubhouse for the defibrillator, whilst we would see what we could to help.

When we got there we couldn’t find a pulse, but given none of us had ever looked for one before it didn’t mean he didn’t have one.  We tried the breath and pushing the chest but the man’s body kept making noises and we panicked that we were making it worse.  We decided the best thing to do was to try and find someone who did know CPR, and sprinted round the course like madmen trying to find someone.  Eventually I found a couple who could help and they took over.

In what seemed like an age later, and what in reality was at least half an hour, the paramedics arrived.  They arrived via golf cart, and it was quite a sight: three paramedics on hanging off the cart with another running alongside, all in full uniform, like superheroes coming to save the day. 

But unfortunately it was too late.  Maybe competent help at the outset would have helped him, but by the time the paramedics arrived there was nothing they could do. 

It is easy to look back and try and apportion blame: blame to myself for not learning CPR, blame to the golf club for not having a defibrillator, blame to the French ambulance service for taking so long to respond to such an important call.  But in the end blame doesn’t help.  I think what is important is to try and take the learning and understand what we can do differently.

Recently I came across a Ted Talk by Eli Beer.  He speaks of how he took an experience not dissimilar to mine and set up a community rapid response service in Jerusalem to support the ambulance service.  They take thousands of volunteers who fill the critical gap between the ambulance call and their arrival.  They save people that otherwise would not be saved.  The response time is three minutes.

And it is not a one off.  They have recently started in Panama and Brazil.  It could be set up anywhere.  As he says, ‘We all want to be heroes.  We just need a good idea, motivation and lots of chutzpah, and we could save millions of people that otherwise would not be saved’.

I wish I could have done more to help on that golf course, and I wish a service had been in place that could have responded more quickly.  As our ambulance services struggle to meet their response times, is it time for us in this country to look at this approach, and to turn our aspirations of local integration into something that tangibly saves lives?


Remember independent bookstores?  There was a time when they were the sole provider of must-read bestsellers.  Each sold at full price and carried a 40% profit margin.  Business boomed.  But then along came book megastores like Borders Books and Waterstones.  They had more inventory but needed traffic, so sold bestsellers at hugely discounted prices.  End of independent bookstore profits.

They regrouped and focused instead on niche markets with targeted discounts in these areas.  Then came Amazon, with its selection and discounts across the board, and this sealed their fate.  Books are more available (and cheaper) than ever, but independent bookstores are, sadly, now a dying breed.

What did it feel like when the owner of one of these stores heard that Borders Books was opening across the road?  How did they then feel when they heard that Amazon was setting up an online bookstore? 

By now you might be wondering why I am writing about books!  Is the story of independent bookstores relevant to primary care?  The Royal Pharmaceutical Society certainly thinks so.  In its new document, ‘Now or never: shaping pharmacy for the future’.  (find it here), point 1 is ‘The traditional model of community pharmacy will be challenged as economic austerity in the NHS , a crowded market of local pharmacies, increasing use of technicians and automated technology to undertake dispensing, and the use of online and e-prescribing bear down on community pharmacies’ income and drive change.

It goes on to say, ‘In a market which has become increasingly crowded, a recent report by AT Kearney estimated that these challenges would reduce the profits of the average community pharmacy by 33%, resulting in the closure of 7.5% of all England’s community pharmacies by 2016.

These pressures will continue and intensify past this date, and community pharmacy will face significant challenges where it does not (change).

But what about general practice itself?  The advent of PMS and APMS contracts signaled a desire to broaden the range of general medical service providers, and it was almost in response to this that some practices started the uncomfortable conversations with their neighbours about mergers.  But a much more fundamental shift is happening: the advent of integrated care.

The system is no longer prepared to accept general practice operating in isolation, with the inherent variation that multiple small businesses present.  Some Foundation Trusts are looking at general practice and exploring how it fits within their model of integrated care.  My view is that it is only the general ignorance that resides within secondary care about the operation of general practice that has prevented this happening further and faster. 

But a more real and present danger are community trusts.  If I ran a community trust the first line of my strategy would be to become the lead provider of primary and community care for specific locality areas.  For community trusts to secure the investment that has historically gone into hospitals they need to reduce demand, and the only way they can do this is to partner effectively with (take over) general practice. 

General practice’s ‘amazon moment’ is actually the Better Care Fund.  Millions of pounds are being invested into community health and social care with clear markers of success predicated on managing emergency demand.  Whatever plans are made, they will only be successful with general practice at the core.  This cannot be as a collection of disparate providers; someone is going to need to bring practices together.

So the race is on for general practice.  The runners are Foundation Trusts, community trusts and general practice itself.  My worry is that the majority of general practice is looking out of the window with an ‘on-line bookstores will never catch on’ mentality.  If it is, I fear the fate of the small businesses that make up today’s general practice will mirror that of independent bookstores.


It was never going to be easy for CCGs, as membership organisations of GP practices, to be effective commissioners of general practice.  This has been brought into sharp focus by the planning guidance, which states this,

36. CCGs will be expected to support practices in transforming the care of patients aged 75 or older and reducing avoidable admissions by providing funding for practice plans to do so. They will be expected to provide additional funding to commission additional services which practices, individually or collectively, have identified will further support the accountable GP in improving quality of care for older people. This funding should be at around £5 per head of population for each practice, which broadly equates to £50 for patients aged 75 and over.’

The first thing to say is that no one was expecting this within the guidance.  And the result of this is, frankly, confusion.  There are a number of practices who understandably, because of the link in the guidance to the over-75s, have assumed that this funding is the replacement funding for the retired QOF points.  Interestingly I asked a number of individuals at a regional and a national level and none were clear whether there was a link between the two or not.  Eventually I found out from a senior member of the GPC that there is, conclusively, no link; the retired QOF points have been replaced by an uplift in the global sum.  But the confusion is important.  It is one conversation for a CCG to have with its member practices as to how the £5 should be invested when it is ‘new’ money; it is quite another when it is money taken off the practices via another route.

A further issue is the complication of timing.  CCGs are responsible for commissioning local enhanced services (LES) from general practice.  As from April these enhanced services can no longer be contracted for as enhanced services within the overall framework of the core GMS/PMS contract, but need to be contracted separately on standard NHS contracts.  Now, this might not be much of a problem in many areas, but in larger CCGs it is. 

This is because the legacy passed by historic commissioning organisations is often one of differential enhanced services being available within even relatively small geographical areas.  Through the passage of time, often going back 10 or 15 years, different deals were done in different places where different enhanced services were moved (or not) into MPIG or baseline or who knows where.  So what this means is that CCGs either have to decommission the service or make it available to all practices and potentially other providers. Neither are particularly attractive options. 

CCGs are accountable for improving quality and outcomes through effective stewardship of NHS resources, and at the same time are membership organisations of a collection of practices.  The reality of commissioning any service direct from member practices means that there will be occasions when the CCG has to make decisions that will be unpopular with some or all of the practices (because the decision negatively impacts upon the practices as businesses), because of its overriding duty to the population that it serves.  Decommissioning LES’s is one of these decisions.

So the question for CCGs (where this is an issue) is whether to link the decommissioning of existing LES’s with the £5 per head, or whether to treat the two completely separately.  The challenge is to ensure that, whatever decision the CCG takes, it is able to realise maximum value for patients for the money it invests.

A further issue is whether to set the expectation that the funding streams that are created are recurrent or non-recurrent. Paragraph 37 of the planning guidance states,

‘Practices should have the confidence that, where these initial investment plans successfully reduce emergency admissions, it will be possible to maintain and potentially increase this investment on a recurrent basis’

This is a fudge.  To create real change providers, whether they are practices or anyone else, need to take on staff and make them part of core business.  When funding is only available on a temporary basis how are organisations, particularly small organisations, supposed to effectively staff the new services?  CCGs need to be bolder and be clear whether the services they put in place are going to be commissioned recurrently or for one year only if they really want them to be successful.

And of course underpinning all of this is the need to transform general practice.  This is a key part of many CCG strategies for their local health economies.  We have considered previously on this site how this might happen (  The mandate to create funding of £5 per head of population is an opportunity to accelerate the transformation of general practice, and so consideration of how to achieve this has to form part of CCG thinking. 

So is the £5 per head of population an opportunity or a curse?  The money could provide the catalyst that is required to support the key role that general practice has within whole system transformation.  The challenge is whether CCGs can do this without losing their member practices along the way.


3 Ways to Create Trust

How do you create trust?  Is it even realistic to think that organisations that are competing with each other for increasingly scarce resources are going to be able to trust each other enough to allow credible whole system plans to be developed?

Joint working is essential, but the barrier to it often boils down to one of trust.  Do the CCG and council trust each other enough to pool budgets? Do the hospital and the CCG trust each other enough to enter a risk sharing agreement?  Do general practice and community services trust each other enough to build a single staffing model across a locality?

This can become a chicken and egg type scenario: we don’t trust each other enough to have a single health economy plan rather than a set of organisation specific plans, and we can’t develop trust because we are not working together closely enough.  So if trust is the secret ingredient, how do we create it?

Well I don’t claim to know the answer, but I was at a session with the previous NHS Confederation chief Mike Farrar recently and asked him this question.  His answer was so good that I thought it only fair that I share it with you!

He said that there are three ways to create trust.  The first is to agree a shared sense of purpose.  He said that many health systems do not put enough effort into this.  A system plan is produced, it goes to a whole system meeting, and is generally agreed.  What doesn’t happen is a stress testing of the purpose or a putting it under the fire of different scenarios.  Organisations don’t take the aims of proposed whole system plan back to base and work through with their Boards as to how the goals of the system can match with the goals they have set for their organisation.  More effort here, according to Mike, is an essential foundation to building trust across the system.

The second is to establish system wide clarity on the approach to competition or collaboration.  There needs to be a shared understanding as to how this will work across the health economy.  What doesn’t work is asking groups of clinicians from all organisations to work together to design a new model of care, and then the CCG springing a procurement on the providers that is not expected.

This does not mean that the CCG has to say that they will not be putting any services out to tender or that they will be procuring everything.  What it means is that a framework is established so that everyone is clear when services will be procured and when they will be developed through collaboration.  The rules of engagement need to be clear and signed up to by all partners.

The third is to establish who the system arbiter will be.  Given the challenges that all health economies face it is inevitable that there will be issues on which organisations do not agree.  It is not good enough to simply say that decisions will be taken that are in the public interest, because this can often be argued both ways. 

There needs to be agreement as to whether deviation from the collective agreement is ever acceptable, and if so in what set of circumstances.  Systems must establish an agreed point of arbitration, which everyone signs up to before such a situation arises, and which everyone agrees to abide by when a decision is made.

Trust is a critical but elusive ingredient of effective whole system working.  The current environment and the challenges that we face dictate that there is not enough time to spend years building it up, but what I think Mike’s answer has provided is a set of actions that systems can take now to make their 5 year strategies much more likely to deliver.


As CCGs consider their 5 year strategies to improve health outcomes and ensure maximum return on NHS funding, one of the questions that arises is whether we should incentivise individuals to be healthy. 

In South Yorkshire and Derbyshire a pilot scheme offering mothers £200 in shopping vouchers to encourage breastfeeding has been set up.  Breastfeeding has been shown to reduce cases of stomach problems, asthma and other respiratory conditions.  The business case is relatively straightforward: the cost of the incentives will be more than outweighed by the benefits realised later on. 

So is this, and other schemes like it, an approach that CCGs should be rushing to adopt?  Does the business case stack up, both on outcomes and financially?  Well there are other examples to learn from.  In 2009 a weight-loss scheme, Pounds for Pounds, was set up in Kent which offered participants cash payments of up to £425.  Less than half achieved significant weight loss and a high drop-out rate meant that evaluators were unable to recommend it as a way of tackling obesity.

However, a stop smoking scheme in Dundee had more success.  The NHS there ran a two-year programme offering smokers £12.50 a week to quit smoking.  By the end of three months, nearly a third of participants end up kicking the habit, more than twice as many as other smoking cessation projects achieved.

There are a number of arguments against this type of approach that I don’t intend to go into here, such as whether it creates perverse incentives, whether it is patronising, and whether it will simply result in paying people for something they were going to do anyway.  But there is one point that I do think is particularly important, and this is best made by Harvard University political philosophy professor Michael Sandel.

Professor Sandel’s lecture ‘Why we shouldn’t trust markets with our civic life’ (you can find it here) tells the story of a Texas policy that awarded children two dollars for every book they read.  He then asked the audience what they thought of the approach, and in discussion concerns were raised about the impact on the long term motivation of the children to read.

Sandel’s argument is that, when considering non-material goods, market mechanisms (e.g. putting a price on something, or using cash incentives) can actually change the nature of the goods. So if we pay children to read books, it can change their motivation to read and the types of books they read.  A key outcome of the Texas study was that children read shorter books!

He says that economists assume markets are inert, that they do not change the products that undergo market exchanges. This is likely to be true for material objects. However, for non-material values like learning and education and health, this is not true.  For us this means that the value of stopping smoking or breastfeeding or losing weight actually changes if we pay for it.  We risk eroding the intrinsic value of these things by paying for them.

For health the unintended negative consequences could be serious.  Will intermittent smokers start to smoke in order to receive the incentive to stop smoking again? Will obese people become morbidly obese to receive the incentive payments to lose weight? More importantly, will the value placed by individuals on their own health become a function of the return they receive for it, rather than something held as valuable in its own right?

Sandel himself says, ‘It is not about inequality and fairness but about the corrosive tendency of markets. Putting a price on the good things in life can corrupt them. That’s because markets don’t only allocate goods; they express and promote certain attitudes toward the goods being exchanged. Paying kids to read books might get them to read more, but might also teach them to regard reading as a chore rather than a source of intrinsic satisfaction.

‘Some of the good things in life are degraded if turned into commodities. So to decide where the market belongs, and where it should be kept at a distance, we have to decide how to value the goods in question—health, education, family life, nature, art, civic duties, and so on. These are moral and political questions, not merely economic ones. To resolve them, we have to debate, case by case, the moral meaning of these goods, and the proper way of valuing them.’

So for CCGs this approach is not something that can simply be adopted.  As leaders with responsibility for population health we need to carefully think through all the decisions we make, and the consequences that these will have not just on the balance sheet but on society as a whole.  Health and wellbeing boards are the perfect place to ensure these issues are fully debated on an individual basis, and it is our duty to ensure that this happens.