Clinical Commissioning Groups Information

The NHS CB has published on a public website papers for its board meeting on the 2^nd February.  You can find them here:

http://www.commissioningboard.nhs.uk/2012/01/26/board-meeting-020212/

The papers cover a number of areas relevant for CCGs, in particular: Organisational Design of the NHSCB; Governance for CCGs; Authorisation of CCGs; and Commissioning Support.  The only wholly new paper is the one on the Organisational Design of the NHSCB.  The CCG Governance paper was produced in draft last year and while it has been updated contains only minor changes.  The CCG Authorisation paper was produced in September last year, and the Commissioning Support paper has been available in draft since December last year.  Most of what is ‘new’ appears in the covering papers, and for those who do not have a spare half day to read through everything our advice would be to concentrate your efforts there.

Key messages for CCGs

What CCGs are really looking for out of the Organisational Design paper is what it means in terms of how they are going to be managed.  Some of the answers are starting to emerge.  There will be local offices of the NHS CB that outside of London map more or less to the existing PCT Clusters.  Each will have a local office director, a medical lead responsible for direct commissioning, a head of finance responsible for CCG assurance and a nursing lead.  According to the Health Service Journal (26/01/12 p4) Bill McCarthy, NHS CB Managing Director has, ‘urged PCT Cluster Chief Executives to consider becoming Director of their local board office’.  So now we know that there is a high probability that the current PCT Cluster CEOs will have the main responsibility for performance managing CCGs, and that they will do that through their Head of Finance (?existing Cluster Director of Finance) and a team of about 10 staff dedicated to ‘CCG assurance’.

So what does this mean for CCGs today?  It means maintain positive relationships with your PCT Cluster CEO, Director of Finance and Director, Medical Director and Director of Nursing, because many may not be going anywhere fast.  As we move into ‘shadow running’ next year they will be taking on the NHS CB role of ‘providing development support, and monitoring performance and outcomes’.  Expect them to have a significant role in the authorisation process!

The other take away message is the strong emphasis there is going to be on the Commissioning Outcomes Framework.  PCTs were not set up to drive outcomes in the way that CCGs will be expected to.  CCGs need to be considering how they will establish their infrastructure to ensure they are driving improvements in outcomes.  Quality leads will need to take on a dual responsibility for improving outcomes as well as quality assurance.  CCGs need to be framing the support they will be receiving from public health in terms of the Commissioning Outcomes Framework, and ensuring they are driving the way the Health and Wellbeing strategy is being shaped locally to reflect this.

The most noteworthy fact about the governance document is the gap that exists between the governance requirements of CCGs, and the governance documentation that CCGs are currently putting together.  Many CCGs claim to have a constitution signed by all member practices, but the reality is these will need tearing up and starting all over again.  The failure to produce a model constitution by the NHS CB to date (it was initially promised by the end of December) I suspect will come back to haunt them, because CCGs are in for a shock when they see it, and it will be a significant challenge for these to be ready in time for authorisation.

The new information about authorisation appears in the covering paper.  There will be two phases to authorisation.  The first pre-assessment phase will be run by the existing SHA Cluster.  The previous outline of further authorisation gateways to include governance in January and leadership in March has been changed to the production of ‘development checklists’ covering configuration, governance, leadership, commissioning support, planning and core infrastructure.  This appears to be a moveable feast, so expect regional variation and more changes to come in this area.  The second phase is formal assessment by the NHS CB.  Applications will be in 4 tranches, with the first in July (completing in October) and the last in October (completing in January).  It does not take a genius to work out that if 220 authorisations are to be completed start to finish in 6 months the majority of the process will have to be carried out by the existing PCT Clusters.  A big question for CCGs is whether there is any benefit in going in an early tranche, or whether they would be better learning from those brave (daft) enough to go first.  Expect CCGs to start fighting to be part of tranche 4 rather than tranche 1.

The Commissioning Support documentation is the one released at the end of 2011.  The interesting expectation is that CCGs will have at least shadow SLA arrangements in from April 2012.  A big call for CCGs is do they push for very detailed specifications (which push a ‘work to contract’ mentality and create arguments when work is required by the CCG that has not been specified) or very loose specifications (which create arguments because of differing levels of expectations on the two sides as to what will be provided).  It seems there is very little time for CCGs and commissioning support organisations to work this through and get the balance right.

‘A good question is never answered.  It is not a bolt to be tightened into place but a seed to be planted and bear more seed toward the hope of greening the landscape of idea.’ John Ciardi

There are many questions that those involved with CCGs have.  These range from the most basic (e.g. what is a clinical commissioning group?) to the highly complex (e.g. how do I maintain practice engagement while meeting all of the authorisation requirements?).

Different people have different levels of involvement with CCGs.  The questions those leading CCGs have are different from those of the grass roots GPs, which are different from those working in a hospital, and which are different again from those simply looking in and wondering what is going on!

At CCG information we aim to provide opinions, discussions and debate based on a real understanding of CCGs for everyone who is interested.  So let us know what your questions are, the things that you are finding it difficult to understand, or areas that you want help with.  We don’t claim to have all the answers, but we do believe that by discussing the right questions we can play our part in enabling CCGs to be the force that they have the potential to be.

Contact us with your questions by email mail@ccginformation.com or post a comment below.

‘How does one become a butterfly?’ she asked pensively.  ‘You must want to fly so much that you are willing to give up being a caterpillar.’  Trina Paulus

Much is currently being made of CCGs being ‘membership organisations’.  The CCG is the practices and the practices are the CCG.  There is no separate CCG to the member practices.  Barbara Hakin is clear that failure to grasp this point will see CCGs struggle in the authorisation process. 

The point that if CCGs somehow become separate from their member practices they will fail is a sound one.  The unique advantage that CCGs have is precisely that they are constituted of their member practices.  If they become distant, separate, top down organisations they will be no different from PCTs.

However, understanding the concept of a membership organisation is quite different from putting this into practice.  How realistic is it that in a 50 practice CCG every practice will feel total ownership of every decision made?  As soon as the CCG takes a decision that a member practice disagrees with (which it will inevitably need to), the practice will claim that the CCG ‘is acting like the PCT’ (i.e. making decisions they do not like).  Even as a membership organisation CCGs cannot keep all of the practices happy all of the time.

The governance of CCGs is critical.  What will determine whether the governance is successful is whether the practices operating within the governance structure retain a sense of ownership of the CCG, as well as the ability of the CCG as a collective to manage risk.  If managing risk effectively is achieved at the expense of practice engagement, all is potentially lost.  Equally if keeping practices happy means that difficult conversations are avoided then the chances are that issues will be being stored up for the future.

The governance must include the agreement between the practices as to how they will manage risk.  It will therefore need to prescribe the actions required by each practice as their part of managing risk.  It will also need to include the consequences of failure to carry out these actions by any member practice.  It will feel onerous.

It is in this context that the GPC guidance to practices stating that practices should not sign ‘onerous’ practice agreements is extremely unhelpful.  These agreements are critical and will be the foundation of CCGs as membership organisations.  To be effective they need to be detailed and create clear boundaries for acceptable behaviour.  CCGs that swerve this now and develop bland constitutions are storing up trouble for the future.  Better to have the conversation in the hypothetical than to wait for a problem to arise and find there is no mechanism to deal with it.

Practices that want their CCGs to fly must put their individual practice focus to one side when developing the governance.  They must have the difficult conversations about what being part of the collective means in reality.  The governance must specify how the practices will change.  It is only then that CCGs will have the potential to fly.

‘Size matters not. Look at me.  Judge me by my size, do you? Hmm? Hmm? And well you should not.  For my ally is the force, and a powerful ally it is.’ Yoda, Star Wars.

Much has been made of the size of a clinical commissioning group (CCG).  Debate rages as to the elusive ‘right size’ of a CCG.  Proponents of big CCGs argue that the small CCGs cannot function effectively due to the restrictions of the management allowance of £25 per head of population.  Proponents of small CCGs claim large CCGs are PCTs recreated and lack real GP engagement.

My concern is not with very big CCGs or very small CCGs.  My concern is with the reported 163 CCGs (out of 279 – as reported by the Health Services Journal 5/1/12) that are between one and three hundred thousand population.  This is the worst of both worlds.

The ‘force’ of CCGs is the ability to make every GP an active commissioner.  This might mean adhering to agreed pathways or agreeing to have their referral reviewed by a peer before they are sent.  Alternatively it might mean leading a contract negotiation or reviewing the mortality rates of the local hospital.  The level of involvement can vary, but participation by all is the key to success.

So what is the problem with an average sized CCG?  Well a very small CCG covers a population where all the GPs know each other, share the same concerns, and can hold each other to account.  There is no hiding place because there are only a small number of practices involved.  If one is not participating the others will tackle it.  In a very large CCG the size forces the organisation into ‘localities’ or some similar sub-structure which can allow the same benefits of the very small CCG to be achieved.

But CCGs where the population is 1-300,000 are looking at between 10 and 30 or even 40 practices being involved.  The temptation will be to try and run the group as one big collection of practices.  It is hard for 30 practices to work effectively as a single group together.  The GPs do not all know each other.  The needs and requirements of the population will vary between different practices.  Some practices will rarely contribute.  It is much easier to hide in a group of 30 than a group of 6.

Governing Body meetings may end up with a representative from every practice.  If so they become unwieldy in size and high quality, timely decision making will be difficult.  Alternatively a select few will make decisions on behalf of all, but then it will be difficult for all to feel they have been able to contribute when difficult decisions are made.  If practices do not sign up to a decision that has been made, and do not feel they had chance to influence it, chances are they will not take the necessary steps to implement it.

So what should these CCGs be doing? Well for any population over 100-120,000, or where there are more than 10-15 practices (15 very small practices can probably work effectively together, but 10 large practices is probably the maximum), CCGs should consider introducing a locality structure.  Practices should be grouped together into self managed accountable units as part of the overall CCG structure.

It is not the size of the CCG that matters; it is the ability to harness the force…

2012 will be the first real year of the Clinical Commissioning Group (CCG). Responsibility will come quickly. So what should CCGs be doing to ensure they are ready? Listed below are the top 10 things all CCGs should be doing now.

1. Resolve Size Issues
CCGs are either too small or too big. There is no magic ‘right size’. Small CCGs are too small because they cannot operate effectively within the running cost allowance. Large CCGs are too big because they lack local ownership.
Action: Small CCG – create a clear plan as to how you will manage at the size you are, and get this plan agreed by the PCT Cluster and SHA Cluster. If they will not agree it take charge and find a merger that will work best for you.
Large CCG – Establish an effective locality structure, where each locality operates with real autonomy and accountability.

2. Develop an Effective Constitution
In January there will be a ‘governance gateway’ for CCGs. So the time of waiting for someone else to write a constitution that can be copied is over. The constitution and associated documents cannot really be copied anyway, as each CCG needs to identify how it wants to work for itself. It represents the agreement between the practices within the CCG as to how they will work together.
Action: Identify how the practices will share the risks they are collectively managing. Specifically address what will happen if one practice is not performing. How will you determine what constitutes ‘not performing’? How will you resolve disputes between practices?

3. Ensure the Composition of the Governing Body meets the Guidelines
CCG Boards are going to be known as Governing Bodies. Guidance on the composition of CCG Governing Bodies has now been released. Essentially they require at least two lay members, a nurse and a secondary care consultant. These need to be in place for authorisation and will take time to get right, making this an action for now.
Action: Check the composition of your Governing Body meets the guidelines, and if not make the necessary changes.

4. Put the Right People in the Senior Management Roles
There will be a leadership gateway for CCGs in March 2012. Those in the key leadership roles within CCGs will be assessed as part of the authorisation process, with national assessment centres as a minimum for the Accountable Officer and Chief Finance Officer (CFO). The GP Chair and Accountable Officer have to be two separate people.
Action: Ensure individuals of sufficient calibre are in the leadership roles, and if not change them. Better for CCGs to control this themselves than have changes imposed by the NHS Commissioning Board.

5. Balance the 2011/12 Books
Authorisation requires, we are told, CCGs to be able to demonstrate an (as yet unspecified) track record. A key component of this will undoubtedly be an ability to discharge the statutory duty of breaking even. CCGs need to take action to ensure that the nominal delegation of budgets from PCT Clusters translates into them actively controlling the actions needed to deliver the PCT control totals for 2011/12. Some PCT Clusters are finding it easier to let go than others!
Action: Pressure the PCT Cluster to delegate budgets and release control. Take the necessary steps to ensure the 2011/12 financial targets are achieved.

6. Take Ownership of the QIPP Plan
If the PCT Cluster has delegated the budget to the CCGs but is keeping control of the QIPP plan and delivery, it is safe to assume no real change has occurred. In many places CCGs are being asked to manage referral rates and make some additional prescribing savings, but overall management of the QIPP plan is sitting with the PCT Cluster. This has to change if CCGs want to be able to give a reasonable account of themselves in performance management meetings with the SHA Cluster (who will expect more).
Action: Take ownership of the QIPP plan, review what will work, take out what will not and replace with more effective schemes, and actively manage delivery.

7. Deliver a Credible Set of Commissioning Intentions for 2012/13
There is a lot of talk about a key requirement of authorisation being a ‘clear and credible plan’. Wherever CCGs are now, they need to be ready to be leading commissioning from April 2012 at the latest. Requirement one for this is a strong set of commissioning intentions. By now these should be nearly complete.
Action: Finalise a set of commissioning intentions that the whole consortium can stand behind. Do not delegate this to a single individual, but create a process that ensures whole CCG ownership, as the whole CCG will be required to deliver them next year.

8. Lead negotiation of 2012/13 Contracts
And if CCGs are to really own delivery next year, they must be responsible for agreeing the contracts that will determine what needs to be delivered. This means more than pitching up a GP (when one is available) to the contract meetings. It is the creation and execution of a negotiating strategy.
Action: Wrestle control of the contract negotiations from the PCT Cluster, and bring contracting expertise into the core CCG team.

9. Specify Commissioning Support Requirements
The creation of commissioning support continues to become more and more complex. CCGs for now need to be focussing on what they can control. This is the clear identification of the elements of commissioning they want to deliver themselves, and the elements they wish to procure. For those they wish to procure they need to specify exactly what they require from commissioning support providers. Where they feel unable to do this, CCGs must focus on accessing the expertise to enable them to produce high quality, detailed specifications.
Action: Create detailed specifications of your commissioning support requirements, accessing expert help to do this where you need it.

10. Influence the Design of the Health and Wellbeing Board (HWB)
Although CCGs will not chair the HWB, it is critical they actively shape the way that these boards will work, how the Health and Wellbeing Strategy is developed, and how the relationship between the CCG and HWB will operate. It is far better to have a collaborative partnership arrangement in place than an adversarial scrutiny style relationship. HWBs have the potential to make life very difficult for CCGs in the future, so action now to prevent this is vital.
Action: Take an active role in the design and set up of the Health and Wellbeing Board.

So there is plenty for CCGs to be getting their teeth into in the New Year! We will explore each of these topics in more detail in coming weeks. We will consider exactly what CCGs need to be doing to tackle the ten New Year challenges.