Archive for April, 2012


Potentially the biggest challenge facing CCGs today is delivery of the 2012/13 savings (or QIPP) plan.  As the spectre of authorisation grows, it would be a brave CCG that entered the process as it was falling significantly behind on its delivery plan.  Good CCGs will have broken the plan down to practice level so that it is clear what each practice is required to deliver, in order that the CCG as a whole can deliver its plan.  This is the core strength of CCGs: that they are able to develop plans that are owned, supported and driven by their member practices.

But many practices are not as signed up to the whole commissioning agenda as some of their more enthusiastic leaders.  They have felt the extra workload that comes with being in the CCG, such as reviewing partners’ referrals before they are sent, following rafts of new protocols, and receiving calls from ambulances and A&E when their patients have accessed the service ‘inappropriately’.  The prospect of carrying out even more work ‘for the good of the CCG’ in many places is starting to grate, and the ‘what is in it for me’ question is coming to the fore.

Enter the question of incentivisation: should CCGs be incentivising their practices to deliver their share of the commissioning agenda?  Or is this now part of core general practice, and should more focus be on developing a system of penalties for those not pulling their weight?  Is it even ethical for CCGs to pay practices for delivery?  Isn’t there something morally wrong about paying practices ‘not to refer’?

This is a difficult question (note the resounding silence on the once heralded quality premium).  But it is a fundamental issue, because at its heart lies grass root GP engagement with CCGs.  If these GPs disengage (and engagement is not a once won forever held commodity, it can slip through your fingers at any point) then commissioning reverts to the preserve of the few and loses the power it has from the many.

A helpful starting point is to consider why a CCG might incentivise its practices.  The fundamental strategy of most CCGs is to shift activity, workload and resources out of hospitals and into community and primary care.  But if you speak to most GP practices they are already struggling with capacity. They can see no mechanism which will create the resource required for them to take on this new work.  CCGs, despite the much-heralded conflict of interest, do need to invest in primary care.  They do need to find a way to create the capacity that will enable them to fulfil their ambition to shift resources out of hospitals.

This investment needs to be significant.  LES’s that generate £5000 a year do not create enough funding for a practice to take on new staff or build capacity.  There also needs to be a degree of certainty attached to it.  If delivery is outside of the practice control it will not lead to the investment in capacity that is required.

CCG incentivisation of delivery of plans at practice level is a mechanism for investing in the capacity required in primary care to create the radical shifts in activity that will ultimately determine the success (or otherwise) of CCGs.  As member organisations CCGs need to find ways of driving and maintaining the engagement of every member of every practice.  They need to create compelling pictures about future models of primary care, and a clear route map as to how these are going to be achieved.  Delivery of this year’s plan needs to be the first step along this journey.  Payments for delivery are not payments to line the back pockets of member GPs.  They are returns for the investments required for practices to be able achieve delivery in the first place.

So create a LES.  Make it significant.  Put the majority of payment based on delivery at practice level.  Make it significant enough so that practices will invest to ensure they achieve.  Create metrics in the LES so that as a CCG you know that it will only be delivered by actions taken at practice level.  Do not structure payments so that they stifle innovation – base them on delivery of outcomes, not on following processes.  Do not worry about the practices that do not deliver – if you are paying a percentage of delivery, non-delivery costs nothing.  Understand that the payment itself is an investment in primary care to accelerate delivery of the future.  And trust that the engagement this will drive at individual GP level is priceless.



The expectation that Clinical Commissioning Groups (CCGs) will accelerate the shift of workload and resources out of hospitals into primary and community care is high.  Many believe that whether or not CCGs are successful will be determined by their ability to achieve this.  But what the formation of ‘PropCo’ does is severely restrict this ability, and here we explain why.

For those who do not know what PropCo is, it is a new national property company owned by government that will take over the ownership and management of the primary care trust estate.  The formation of NHS Property Services Ltd (PropCo) was announced in January. Clarity as to how the private sector will be involved is awaited, but the possibility of the company being sold by the government has not been ruled out.  It is already clear that it will receive no NHS or government funding, and is expected to become a source of income generation for its owners.

Those in favour point to the fact that it solves the problem of where the estate will go following the abolition of the PCTs and SHAs.  Finance Directors are excited by the removal of buildings from the balance sheet.  The DH see the ability for greater efficiency in the management of the estate, with resources freed up to improve properties and invest in other frontline services.  In fact it is fair to say that there has been very little reaction to the announcement of the creation of PropCo since it was made in January.

But for CCGs this has significant implications.  It makes the shift of resources out of hospital much more difficult.  Below are listed 5 reasons why:

1.       Benefits of Capital Sales will go to PropCo

This may seem obvious, but where capital funding is scarce it is currently increasingly common for NHS organisations to sell land or buildings it owns in order to fund developments on other buildings, or on the same building on a smaller footprint of land.  This opportunity will be gone with the transfer of buildings to PropCo.  The new company will be driving better use of buildings (potentially by increasing running cost charges) so that buildings are vacated and can be sold, and pocketing the benefit.  None of that benefit will be coming directly to CCGs.

2.       Running costs of Community Services will go up

A key argument to justify the creation of PropCo is that the running costs will be reduced.  While this may or may not be true in the round, it is unlikely to be the case for CCGs wanting to increase their usage of the estate.  CCGs will be looking to expand service provision in primary and community care and so will have an increased need for estate.

If PropCo is not funded by government and is expected to survive by maximising its property portfolio, the immediate concern for all tenants must be whether the change in landlord leads to significant hikes in rent payments to help PropCo build up some working capital. The irony of course is that this may impact not only on the community estate but also on GP practices.  Where rents in PCT owned property are below market value (which is common), PropCo may well be expecting them to rise.  If there is no written lease in place with arrangements for future rent reviews, trouble could well be looming.

3.       Reduced ability to develop community estate quickly

As a limited liability company not an NHS organisation, will PropCo be able to use the procurement frameworks that are in place and available to PCTs?  These frameworks significantly reduce the lead time for the development of new capital projects and if PropCo cannot use them, and it seems unlikely that they will be able to, this will mean that new capital projects that CCGs wish to undertake will take considerably longer to complete.

4.       Loss of expertise in developing community estate

Estates staff in PCTs will transfer to PropCo.  The impact of losing the more traditional estate manager may not be so significant, but many PCTs have invested in strategic estate managers to support the shift of services into primary and community care.  These staff, and this expertise, will be lost to CCGs, and it will be very difficult to attract such staff into posts as all the estate will have been transferred!  Pace in the shift of services out of hospital relies on the rapid development of fit for purpose estate in the community, and CCGs may struggle to find the expertise they need to make this happen.

5.       Opportunities for joint working with community partners reduced

We often see informal arrangements entered into between PCTs and other organisations, where social enterprises or councils are allowed to use space owned by the PCT without any clear documentation. Even where some documentation, such as a section 75 joint partnership agreement or a services contract exists, this may not expressly deal with the occupation of property or satisfy the legal requirements to be a formal right to use that property. This means that when the property transfers to PropCo the new owner may have no legal obligation to allow continued use on the same terms.

The most surprising part of all of this is that it has not been picked up by CCGs as an issue.  It is critical that CCGs look beyond authorisation and this year’s QIPP plan, and ensure that the system they are stepping into is set up to enable them to succeed.



As the number of Clinical Commissioning Groups (CCGs) shrinks and the average size gets higher, more and more smaller groups are ‘federating’ together into a larger organisation.  Here we explore what lessons CCGs can learn from one of the most successful examples of a federation being formed (the six colonies coming together to form a single Australia), and from one of the least successful examples (the brief establishment of a West Indies federation).

So why did Australia succeed where the West Indies failed?  A key reason was that the six colonies of Australia (Western Australia, South Australia, New South Wales, Victoria, Queensland and Tasmania) identified with the overall continent of Australia, and understood that there was a logic to them forming a federation.  The need to work together to protect the vast empty area of Australia was clear.  It is interesting that New Zealand chose not to join, for the very reason that they saw themselves as a different country, with a different climate and separated by the sea.  They did not naturally identify with the proposed federation. It is also worth noting that while the federation is considered to be of substantial importance to many Australians today, in 1901 when the federation was formed many of the general public were apathetic to it, and more concerned with dealing with the effects of the depression of the 1890s.

The West Indies federation was created in 1958 by Great Britain to enable it to become a fully independent state.  It was set up between 24 inhabited islands in the Caribbean, but there was no popular support for it.  Lack of identification with the federation by both the people and their leaders was one of the key problems that the West Indies faced.  People identified with the island they lived on, not the wider federation, and by 1962 the federation had been dissolved.

So the first lesson for CCGs is that the federation must make sense to the members.  There must be a logic to it and some natural sense of community amongst those who are involved.  Artificial constructs are much more likely to fail.  CCGs that widen across county boundaries where no historic links have existed could well be storing up problems for the future.

The Australians identified some clear benefits to federation.  Both Australia and the West Indies were seeking independence from England (there may be some parallels between colonial Britain and the NHS Commissioning Board!).  The Australians were keen to keep out unwanted foreigners, and needed a collective approach to dealing with the unions that were operating across the colonies.  There were also tariffs on the transport of goods across borders and the federation provided the opportunity to improve trade across colony boundaries.

What Australia succeeded in doing that the West Indies did not was driving the delivery of the potential benefits.  The West Indies never achieved a single customs union or freedom of movement.  The Australian colonies felt that if they fell on hard times that the others would come to their aid.  The West Indian island states did not share such a belief.  In the end the Jamaicans felt that achieving independence from England would be faster on their own than as part of the federation, and the federation collapsed.

There are some clear benefits to smaller groups federating together into a larger CCG.  There is buying power with commissioning support services, or the ability to deliver all support services directly.  The management allowance goes much further with statutory overheads only needing to be provided once.  A larger group can have much larger and more powerful voice with external stakeholders, including the NHS Commissioning Board, the Health and Wellbeing Board, and acute trusts. And potentially most importantly the financial position is much less volatile and can be kept much more within the CCGs control for a larger federated group.

But these are only potential benefits. They do not come simply because the group is larger.  The CCG has to work hard to deliver and maximise the benefits.  At the same time it needs to communicate these benefits to the member practices, because as in the case of both Australia and the West Indies they are likely to be apathetic at best to the federation.  Failure to do this will lead to individual groups within the federation thinking they can do better on their own, and the likelihood of the federation breaking up becomes much more real.

Australia had some strong leaders such as Alfred Deakin driving the federation.  They influenced the press where they could to provide a strong, consistent, reinforcing message.  The West Indies were plagued by political feuds between the influential leaders.  The office of the prime minister was weak, so strong central leadership never prevailed.

Strong leadership is needed in all CCGs, but particularly in large CCGs.  The Chair, Accountable Officer and whole Governing Body need to provide strong collective leadership, drive the federation, articulate the benefits of federation consistently and continually, and work together to resolve issues and disputes as they arise in a clear and transparent way.  Federations are fragile, particularly in the early days, and need to be respected and treated with care.  The key message from Australia in 1901 and the West Indies in 1958 is understanding that forming the federation is the point at which the real work begins.

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The most common way people give up their power is by thinking they don’t have any’ (Alice Walker).

Following the passage of the Health and Social Care Bill, it should be a time for CCGs to be harnessing their power and creating the commissioning landscape around them.  It seems however, that at just this very point the power of CCGs is being increasingly eroded by the NHS Commissioning Board.  This is happening in a number of ways:

1.  CCG senior leaders are to be appointed according to an NHS Commissioning Board designed process.  Why is this ok? Why are senior leaders within CCGs accepting this process and meekly complying with it?  Chief Financial Officers have to go through two separate assessments because different parts of the NHS Commissioning Board were not speaking to each other and set up two different processes!  Accountable Officers, many of whom have already given up their share of practice partnerships, are being told that they cannot be appointed until they have 1) been through an assessment centre with no evidence base using quasi-scientific method to determine whether they are suitable or not; 2) been through (yet another) recruitment process within the CCG; and 3) are approved by the NHS Commissioning Board post-authorisation.  How is this a reasonable or acceptable process?  What it does of course is keep direct appointment power by the NHS Commissioning Board over Accountable Officers deep into next year, which in turn reduces the chances of real opposition to the Commissioning Board being vocalised.

 2.  The NHS Commissioning Board is designing an authorisation process that shapes CCGs in the way that it wants them to be shaped.  The rhetoric around co-design turned out to be simply that – rhetoric.  It is mandatory in the Health and Social Care Act that Clinical Commissioning Groups are statutory bodies that carry out commissioning.  CCGs are unwittingly allowing the NHS Commissioning Board to shape the way this happens through the authorisation process.

3.  The expectation of use of Commissioning Support Services (CSS’s) by CCGs and the geographic development of CSS’s.  I understand that there is value in companies determining their core competence and outsourcing to other companies areas that are not their core competence.  What I do not understand is how CSS’s are being developed on a geographic area basis rather than a core competence basis.  It makes no sense.  A CCG needs to be able to access the best supplier of contracting support for the model to work.  Accessing it from the local CSS simply because it is local makes no more sense than providing it in-house.  In addition all CSS’s will be hosted by the NHS Commissioning Board until 2016 and they will appoint all senior leaders of CSS’s.

It is a myth, perpetuated by the NHS Commissioning Board itself, that CCGs are run by clueless GPs and their receptionists, and that the NHS Commissioning Board is preventing the NHS from collapse by intervening in the way CCGs are run.  This is not the case.  CCGs can and are approaching commissioning in much more powerful and effective ways already than were ever achieved by PCTs.  The biggest current risk they have is that they give up the right to choose the way they do business, and assume somehow that the NHS Commissioning Board knows better than they do.  CCGs must find a collective voice, which acts as a powerful antidote to the NHS Commissioning Board, and use the power that has now been given to them by law.  If we do not act soon, it will be too late.

Frank Herbert, author of Dune, sums this up well, ‘If you think of yourselves as helpless and ineffectual, it is certain that you will create a despotic government to be your master.  The wise despot, therefore, maintains among his subjects a popular sense that they are helpless and ineffectual’.

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