Archive for August, 2012


As the new landscape unfolds a clear gap is emerging.  Large scale procurements, strategic planning, indeed any activity that requires an at scale approach, are at risk of falling into no mans land.  If the NHS is to be commissioner-led, then Clinical Commissioning Groups (CCGs) cannot allow this to happen.

Clinical Commissioning Groups need to find ways of working together.  This is not the same as groups of practices working together within a multiple CCG federated structure.  This is about different CCGs developing effective mechanisms of joint decision making, and of creating a clear commissioner voice across an area larger than any individual CCG.

When might this be needed?  The obvious examples are at-scale procurements such as pathology, and service reconfigurations to shape the acute provider environment.  The financial climate means that these types of initiative are going to be more important and more necessary in the future than they have been in the past, and yet there is no obvious mechanism of making them happen.

To be fair, the NHS Commissioning Board (NHSCB) has recognised this.  They have published guidance on collaborative commissioning between CCGs.  You can find it here

As ever, this guidance raises more questions than it answers, and basically sends the message that CCGs need to work it out for themselves.  It does however ensure that the right questions are being asked.  There are two important principles to bear in mind.  The first is espoused in Annex 1 of the document,

“Where two or more CCGs engage in collaborative commissioning arrangements, the individual CCGs will retain liability for the exercise of their respective statutory functions for their areas. This cannot be delegated or shared, and the arrangements must recognise this. Two or more CCGs could have a joint working committee as the hub of their collaborative arrangements, but such a committee could not make decisions directly of its own authority which would bind the CCGs, as legislation does not provide for this.” p22

This creates a real problem for CCGs, as it means that any joint arrangement that is made cannot be binding on the CCGs involved.  All CCGs retain sovereign responsibility for their population.  If a CCG is going to delegate decision making ability to an individual on a joint committee it needs to consult its member practices in order to amend its constitution to enable this to happen.

So the second principle is how CCGs will resolve any differences of opinion, as any arrangements that are developed necessarily preserve the ‘walk-away’ option for any CCG.  The last thing that CCGs need at this point in their collective development is the collapse of any collaborative arrangements, sending a clear signal to providers that the shift to CCGs is strengthening their hand.

It requires CCGs who are forming collaborative arrangements to work through how they will resolve differences of opinion before they occur.  Ultimately CCGs in a group cannot stop one of their number from walking away.  But what they can do is to create a mechanism for ensuring that any differences are given the best possible chance of being resolved, through the development of escalation procedures that may ultimately include the introduction of independent arbitrators.

The pressures of authorisation, coupled with many CCGs operating without a full complement of resource, means that the creation of these arrangements has to date been relatively few and far between.  The NHSCB have promised a model agreement for CCGs in the autumn.  As CCGs develop these agreements they would do well to share them with each other.

Leaders of CCGs should be prioritising building relationships with the leaders of other CCGs.  These relationships are going to be crucial to long term success.  CCGs are not and should not be competing with each other.  They are on the same side and need to work hard at collaborating to ensure that CCGs collectively are successful.

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There was a significant development this week.  David Nicholson wrote a letter to Chief Executives saying that management responsibility was shifting from PCTs and SHAs to the NHS Commissioning Board (NHSCB) from the 1st October.  The letter said,

“For the NHS Commissioning Board, people appointed to the future regional and local leadership roles in the NHS Commissioning Board should take on management responsibility for the teams managing both 2012/13 operational delivery and planning for 2013/14.” ( )

This really is a momentous shift, as PCT Clusters and SHAs are stripped of their power.  But what does this mean for Clinical Commissioning Groups (CCGs)?  Well, it then goes on to say,

“The arrangements I have outlined above will not impact on Clinical Commissioning Groups (CCGs) or Local Authorities as they prepare for their key roles in the new health and social care system.”

Really.  That feels a bit like saying that the manager of a football club will be changed for 6 months of the season, but it will not have any impact on the players.  I am not sure whom David Nicholson thinks is actually doing operational delivery this year, but for the most part it is CCGs and not PCT Clusters.  Shift in ‘management responsibility’ therefore means ‘management responsibility of in year CCG performance’.  

What therefore is the impact likely to be for CCGs, and how should CCGs respond?  Here are 4 key actions CCGs should be taking now:

1. Reset expectations for taking control from 1st April 2013 to 1st October 2012.  There is a window of opportunity that has been created for CCGs to take responsibility early.  There will inevitably be a vacuum as the PCT Cluster executive teams lose control to the NHSCB.  CCGs need to behave from the 1st October as the local system leaders.  Failure to do this now will result in the NHSCB taking over, and this will then prove extremely difficult to change post April.

2. Get hold of the PCT Cluster reserves.  However strong the relationship between the CCGs and the PCT Cluster I guarantee the PCT Cluster will be holding financial reserves.  PCT Cluster Chief Executives and Directors of Finance do not want their legacy year to be one of falling into financial deficit.  The opportunity for them in the delegation of budgets to CCGs was to performance manage QIPP delivery and influence GP behaviour in a way they had never previously been able to, while always keeping a slush fund to ensure end of year balance. 

The problem is these Chief Executives and Directors of Finance are losing control 6 months early, and will be off to pastures new.  It is critical that CCGs have the honest conversation and ensure that they get their hands on these funds, because otherwise they will go to the NHS Commissioning Board.  And if the CCG down the road is in more trouble than you, that is where those funds will end up.

3. Build a relationship with the NHS Commissioning Board.  The change to the new style of leadership will be the greatest tangible impact upon CCGs.  For some this may mean moving to a more directive style, but others may find the style moving in the opposite direction.  Either way the time is now for CCGs to develop an adult-adult relationship with the NHSCB, and move away from the parent-child relationship many CCGs have had with their PCT Clusters.

CCGs must plan their interaction with the NHSCB.  They must always be well prepared, always be knowledgeable about current performance, and always be on top of the finances.  Conversations need to be shaped about what the NHSCB can do for the CCG and not vice versa.  The key is not giving the NHSCB any opportunity to take control of your area.

4. Collaborate with other CCGs.  The NHSCB has an opportunity with this early shift to establish control over CCGs.  Whilst on the one hand this shift gives more freedom than has existed previously to CCGs, on the other it potentially could restrict the amount of freedom CCGs have in future.  To counter this CCGs need to work together.  They need to share information and intelligence on interaction with the NHSCB.  They must create a single coherent voice to enable them to push back effectively when the NHSCB oversteps the mark (which it will!).

The time for CCGs has come 6 months early.  This is an opportunity and at the same time a significant risk.  The government has gone to great lengths to put CCGs in charge.  But at the end of the day the legislation can only ever take us as far as the water.  It is up to us to drink.



The shift of public health to the council is a move which creates real uncertainty as to whose job prevention is.  By prevention we mean those activities which avoid the occurrence of disease.  Clinical Commissioning Groups (CCGs) need to actively formulate a view as to how they see their role in relation to prevention.

There are a number of options open to CCGs.  The first is to continue where PCTs left off.  This view makes the argument that it is impossible for any effective commissioning in health to take place that does not start with a full understanding of the health needs of the population.  A large proportion of the CCG budget is funding the treatment of disease that is preventable.  CCGs need to invest in the prevention of disease if they are to have any hope of being able to effectively commission healthcare in the medium to long term.  The fact that CCGs will be measured according to the outcomes framework reinforces the need for funding to follow outcomes not activity.

There are CCGs actively pursuing this option.  Directors of Public Health have been made part of the Governing Body of the CCG, and structures and ways of working have been developed that enable a real focus on prevention to exist at the core of the CCG.

The second option is for CCGs to make the decision that funding for Public Health has been transferred to the Local Authority, and that as such responsibility for commissioning any activity relating to prevention also transfers to the Local Authority.  Ensuring that there is effective investment in prevention is purely a job of holding the Local Authority to account for the choices they make.

There are many CCGs walking down this path.  These CCGs are watching the public health staff and the public health funding transfer out of the PCT, and are happy that there is one less thing to worry about.  They have little real interest in the offering coming out of the Local Authority in relation to public health, as they do not see the output as their responsibility.  Many GPs never really understood what Public Health either did or was supposed to do, and so the loss of it does not feel that great.

The third option is to sit somewhere in between these two extremes.  The key new component of the new architecture is the Health and Wellbeing Board.  This brings together the Local Authority (and Public Health) and CCGs.  It has a mandate to produce a Health and Wellbeing Strategy.  This strategy should outline (amongst other things) how the Local Authority and CCG (and other players around the table) are going to work together to tackle prevention.

The reality is that effective prevention requires a whole community approach.  The Centre for Disease Control and Prevention in the US has said for some time that improving health requires policy makers, health professionals, transport, education, housing and local community leaders to work together with a single focus.  In the US it runs a Community Transformation Grant programme to encourage this to take place ( ).

The Health and Wellbeing Strategy is a real opportunity for the prevention agenda to be tackled in a much more effective way than it ever has before.  The risk is that is by being the responsibility of a group it becomes no one’s responsibility.  CCGs need to grasp the opportunity to make this strategy effective.  They need to make it central to their own work.  It needs to be a document that sits at the foundation of the CCG’s operating plan.  CCGs may not have to directly invest in prevention, but they absolutely have to ensure that effective prevention occurs.

So whose job is prevention?  It is everyone’s and it is no one’s.  What it presents is another opportunity for CCGs to show leadership and drive the new architecture to make it work.  Ultimately CCGs are about serving a population, and letting prevention fall into no man’s land is a risk to their population’s health that CCGs should not be prepared to take.

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Take the first step, and your mind will mobilize all its forces to your aid. But the first essential is that you begin. Once the battle is started, all that is within and without you will come to your assistance. Robert Collier

There is a key deadline approaching of the 31st August.  That is the date when the Commissioning Support Services (CSS) need to submit their documents for their Checkpoint 3 submissions.  Are Clinical Commissioning Groups (CCGs) going to sign the SLAs by then?  CCGs are concerned with the overly legalistic approach to SLAs that many CSS have taken, and are reluctant to sign the proposed SLAs in their current form.  On the other hand, as with just about everything else, CCGs are being told that authorisation will ‘depend on’ having signed SLAs in place.

So should CCGs sign the SLAs? The obvious answer is only if they are happy with them.  Here are 5 things that CCGs should insist on:

  1. Clarity of CSS Vision.  As we have discussed before on this site, CSS are going to take time to deliver quality product.  This is because of the size and scale of the organisational development journey they need to go on.  Before any SLA is signed, CCGs need to be convinced that their commissioning support provider knows where they are going and has clear, deliverable milestones to get there.
  2. Notice Period.  There are rumours circling CCG-land that CSS are trying to insist upon 12 month notice periods.  6 month notice periods are the maximum that CCGs should be agreeing to at this stage.
  3. Outcome-based Key Performance Indicators.  There appear to be broadly to type of key performance indicators (KPIs) that are being suggested by CSS.  There are a group that appear to be about how the CSS will operate, e.g. quality of staff, speed of response, ease of contact etc.  These should not be pursued.  There is a second group that focus on the outcome of the work, e.g. timeliness, quality etc.  These are the KPIs that CCGs should use to form the basis of the specification.
  4. Value for Money.  One of the key reasons for developing at scale offerings is so that they can deliver efficiency and value for money.  Through agreements of SLAs CCGs need to be driving the efficiency requirement.  However, in the financial planning guidance for Checkpoint 3 CSS are told to include a 4% figure by the NHS Commissioning Board (NHSCB).  CCGs need to decide the amount for themselves, but should use the 4% figure as an absolute minimum.
  5. Client Satisfaction. CCG satisfaction with CSS clearly needs to form a key measure for the SLAs.  The most obvious suggestion for this is a regular (annual?) survey of all CCG staff.  The first survey will act as a baseline, and then improvements against baseline can be incorporated within the SLA.

This first round of SLA agreements with CSS is critical for CCGs.  If CCGs are weak in the negotiation process it sets a terrible precedent for the future.  CCGs need to establish themselves as the client, as those driving the SLAs, and as those with the final say as to what is included and what is not. 

The reality is that CSS need the SLAs signed quicker than CCGs do.  The requirements for their checkpoint 3 are that the SLAs are signed and submitted by 31st August.  Worse for them, in September there is then a CCG survey, followed by a meeting between the NHSCB and CCG leads as part of the process for checkpoint 3, to check on CSS ‘customer focus’. 

CCGs need to use this negotiating position to their advantage, and insist on SLAs that meet their requirements.  Going forward CCGs would do well to find ways of working effectively together, to agree standard contract clauses and a common efficiency requirement, in order to maximise their negotiating power.

At present CCGs seem to me to be keeping their heads down and are avoiding controversy ahead of authorisation.  The time has come for CCGs to start raise their voices, both collectively and individually, and step into the arena.  Failure to start to fight soon will mean that it could be lost before it is even begun.

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