Clinical Commissioning Groups Information

Commissioning support is not working. Something needs to change, or else not only will it fail, but it will drag CCGs down with it. In an uncertain world one thing is certain: it will not and cannot remain as it is now.

CCGs are, by and large, frustrated with their Commissioning Support Unit (CSU). While there are some pockets of satisfaction, it is fair to say most CCGs are planning to change their commissioning support arrangements at the earliest opportunity.

This dissatisfaction exists for a number of reasons. The costs of service are not transparent. They are not comparable within individual CSUs, let alone between CSUs. It is not uncommon for two different CCGs working with one CSU to be paying a totally different price for the same service.

And the issue is not just price. Those leading CSUs seem much more concerned with creating the future rather than fixing the present. CCGs are working hard to get on top of performance and are being thwarted rather than supported by their CSU. It very rarely feels like CSU colleagues are striving to ensure delivery; much more common is passing over problems to CCGs saying that they have done their ‘bit’.

CSUs for their part are frustrated with CCGs. The inability of CCGs to clearly articulate what they want, followed by sniping criticism of any service that is offered, is a recurring gripe from CSUs around the land. As an aside, a good CSU will make it their business to know what CCGs want better than they know themselves, but we have not yet reached this level of customer service from the newly formed CSUs.

So what does the future hold? The authorisation process has constrained CCGs. Few have fancied the challenges of getting in-house services accredited on top of everything else. Most read the runes that authorisation would be a clearer path for those who chose to use CSUs. That process is coming to an end (hopefully – there are worrying plans for ongoing assurance that are a topic for another day), and there are large numbers of CCGs who are just waiting for the opportunity to bring services in house.

I think this is a mistake. The mantra of ‘not becoming the PCT’ extends beyond clinical engagement. PCTs were hampered by the extent to which they had access to first class contracting support and business intelligence. Those CCGs that take these services in house are likely to make an improvement on where things are today, but the potential of where they will get to will be limited forever by the capacity at which they are able to operate.

The future lies in commissioning support providers that are not monopoly suppliers over a particular geography, but rather those that specialise in specific service lines in which they have expertise. The system has made a fundamental error in allowing the CSUs to be defined by geography rather than by service line. But it is one that CCGs can act quickly to rectify.

CCGs will not simply switch from one CSU to another. None are good at everything. They will procure the support they need on a service line by service line basis. At a stroke this will expand the potential market available to CCGs. Good HR and organisational development services can be provided by any large organisation with a strong in-house department. We may decide we want NHS expertise, but this still allows teaching hospitals and national organisations to bid for services that are tendered. Many organisations have strong procurement teams, and local government are a prime example of somewhere that has been doing this better than the NHS for years.

In future, and not the distant future, CCGs will have a range of commissioning support providers delivering high quality services at attractive prices. CSUs will survive only if they decide what they are good at and focus on being the best at it, rather than trying to do everything. To get there CCGs need to work together to ensure that it is ‘buyer power’ (for an article on this click here) that shapes the market, not the NHSCB.

It is up to CCGs to turn the CSU situation around, and to do it quickly. The only thing that will stop us is ourselves if we give up now and in-source everything.

The most common criticism that practices have of their CCG is that it is becoming ‘just like the PCT’.  This is born out of a sense of decision making being distant from practices, from decisions being taken that are unpopular and not understood by practices, and, frankly, by a sense that the bottom line is being put above patient care.

Commissioning in the new world is not going to be easy, whoever does it.  For Clinical Commissioning Groups (CCGs) there will be the need to make tough decisions, where whatever is decided there will be those who are unhappy.  The key difference, however, between PCTs of the past and the CCGs of the future is the establishment of ‘localities’.

Most CCGs have a locality structure of some description.  A locality is a grouping of practices within a CCG.  They are generally (but not always) developed based on geography.  They vary in size, but the prevailing wisdom is that the optimum size for a locality is a population of 50-100,000, and a membership of 5 – 10 practices.  Localities that are too large or contain too many practices become impersonal and mutual accountability becomes harder.  For more on making localities effective see the article ‘How to tackle underperforming localities’ here.

Success for a CCG ultimately will depend on its ability to influence on the one hand its main providers and on the other its member practices.  The locality structure is important because it will ultimately define the relationship a CCG has with its practices.  This in turn will determine the level of influence the CCG has with its practices.  But the existence of a locality structure masks fundamental differences between CCGs in the way that they operate.

CCGs have approached the development of localities in two fundamentally different ways.  There are those CCGs where the majority of decision making, plan development and innovation take place centrally.  The localities are used as mechanism for ensuring effective communication of CCG decision making takes place with practices, and for implementation of those actions that require individual practice action (e.g. reduction of referrals).  For these CCGs the majority (if not all) of the resource is coordinated centrally.

However, other CCGs have devolved more of the resource to the localities.  In this model planning is owned by the localities and coordinated centrally.  Accountability sits primarily with each locality rather than the ‘central’ CCG, and works with the localities being accountable to each other for delivery.

This second model is much harder to put into practice.  For a start it has not been done before, so there is no easy roadmap to making it successful.  There are many pitfalls that CCGs pursuing this route are coming up against, such as working out how to balance the distribution of resource locally and centrally, and putting effective systems of control in place that enable statutory responsibilities to be delivered within a devolved structure.  But if done well it creates real practice ownership of the CCG in a way that the first model will struggle to achieve.

The authorisation process will not have been influenced by which of the two models a CCG has chosen.  But this choice may ultimately have more influence over which CCGs will be successful in the long term.  The relationship between the CCG, with all its statutory responsibilities, and its member practices, with all the pressures they face, will be a critical success factor for the long term success of CCGs.  Localities are the key to making that productive.  Without effective localities CCGs will become a less effective version of PCTs, but with them they have the power to transform health systems.

There is something sobering about reading the Francis Report and trying to fully take in the implications of it with only 50 days to go (and counting!) until Clinical Commissioning Groups (CCGs) take on their statutory responsibilities. 

In the immediate aftermath of the publication of the report the cry is for ‘heads on sticks’.  Whilst Francis has shied away from this, it remains to be seen how this will end up.  What is clear is that for CCGs the buck does not stop with the Governing Body, it stops with the accountable officer.  If there are any Mid Staffordshires in the future, it is clear whose heads they will be.

So what does all this mean for CCGs?  At its heart the Francis Report is about money taking precedence over care, about corporate priorities taking precedence over organisational purpose, and about delivery taking precedence over compassion and kindness. 

First and foremost each CCG needs to be able to answer the question, ‘Why do I exist?’.  CCGs exist to make a difference to people’s lives.  We have discussed this in more detail here.  It is the responsibility now for CCGs to ensure that the failures that occurred at Mid Staffordshire do not happen again.  The system failed to protect patients.  This is the very minimum CCGs need to do.

Whilst the responsibility is great, CCGs as clinical commissioners are the best possible organisations to be taking this on.  The financial reality that we operate in means that there is no ‘throw money at the problem’ response available to the NHS.  The knee-jerk response is going to be more assurance, more inspections, more oversight (cue David Cameron’s inspector of hospitals).  CCGs can offer something different, something more fundamental, something that can drive real improvement as opposed to simply identifying failure.

But to do this CCGs will need to take several actions. First, CCGs need to find more robust mechanisms for ensuring that the messages that come from listening in the thousands of individual GP patient interactions that happen every day are captured and acted upon.  CCGs as membership organisations made up of GP practices have direct access to the voice of the patient.  We must find effective ways of listening to these voices, and acting on what we hear.

Second, and linked to the first action, CCGs need to make listening to the patient the responsibility not of the Governing Body or ‘those involved with commissioning’.  It needs to be the responsibility of every member of staff in every practice across the CCG.  The very fact that the GPC considers ‘boycotting commissioning’ as a potential response to the proposed GP contract demonstrates the distance we have to travel in making this concept a reality.

Third, the fact that GPs see patients every day does not on its own mean that CCGs engage effectively with patients and the public.  Creating a real partnership between the public and the clinicians, where public and patient representatives have a real voice is critical.  Some CCGs already do this very well.  Most of us do not do it as well as we think we do, and all of us need to digest Francis and understand the need to do it better.

Fourth, we need to build on the work that we have started in understanding and tackling variation.  It is a real strength that CCGs are bringing to commissioning, and one that we must strive to build on and develop as we go forward.  Using clinician to clinician conversations to really understand what is going and what the data is telling us, and using this to drive changes in behaviour is an opportunity and a responsibility that we must grasp with both hands.

Finally, CCGs need to hold providers effectively to account.  This particular aspect is one that even pre-Francis has been picked up (cf the requirement for CCGs to quality assure provider CIPs in the Everyone Counts document).  The danger is that CCGs will end up being forced into becoming inspectorates themselves. 

In the recent past, this has developed into an exercise that feels like those who are monitoring are trying to catch the providers out, with adversarial sessions often using previously unseen data to put providers on the back foot. 

CCGs need to find their own style and mechanism for this.  It needs to start with honest clinician to clinician conversations about what is happening.  Clinicians from CCGs need to be visible on provider sites.  CCGs must not be distant, ivory-tower organisations passing judgements from on high.  They must be patient advocates working with providers to ensure that standards are met and continually improved.  They must be part of the solution not just highlighters of the problem.

Yes CCGs need to intervene where substandard or unsafe services are provided.  Ultimately they are accountable for the scope and quality of all the services they commission.  But CCGs are not simply contractors and inspectors.  They are clinical commissioners. 

As CCGs we can make a real difference.  Not only can we prevent the systematic failures of the past from happening again, but we can be the driving force for quality and improvement at the heart of the NHS that will allow it to steer through the difficult times ahead.  We are going to get it wrong sometimes, particularly in the early days, but we must commit not to protecting ourselves but to driving improvements for our patients and our public by being part of the solution.  We must learn from each other and capitalise on the once in a lifetime opportunity that being CCGs as clinically led membership organisations presents. 

The Francis Report presents us with a serious challenge.  Let’s rise to it.

Last week I met up with a friend whom I hadn’t seen for a long time.  He asked me what I did for a living, and I replied that I worked for a CCG.  He asked me what a CCG was.  Good question.  I said it stood for Clinical Commissioning Group.  He was none the wiser.

It is an odd thing that ever since the purchaser provider split was introduced the idea of a ‘purchaser’ of healthcare has not really been understood by the public, or pervaded into the public consciousness.  PCTs were never really able to establish any form of identity, other than maybe as the organisation that wouldn’t fund treatments for specific heartbreaking cases.

The mistake I think is starting with a description of what a CCG is, or worse, a description of some of the legalities that sit around it.  It is a fast track to someone glazing over when you start to talk about being a statutory body that is being authorised by the NHS Commissioning Board with an individual constitution agreed by member practices!

The starting point is to understand why CCGs exist.  Ok, so why do CCGs exist?  Most CCGs have a vision/mission statement that goes along the lines of, ’to improve health outcomes and the quality of health care provision for the local population’.  The job of a CCG is to keep you healthy and make sure you get good care if you get sick.

Whilst this is a noble goal, it remains slightly nebulous.  Isn’t that the role of the local hospital?  Hospitals are easy concepts to understand.  They are where you go when you get sick and it is too complicated for your GP (or if you can’t get through to your GP!).  So what is the difference between a CCG and a hospital?

On the one hand they feel so different that it seems like a ridiculous question, but on the other it is true that hospitals and CCGs are both trying to improve health outcomes and the quality of care that is provided to those who need it.  So what really is different?

At this point there is a route we can choose to go down.  The difference is essentially that CCGs decide how NHS money is spent to keep you healthy and make sure you get good care if you need it, while the hospital’s job is to turn the money they receive from the CCG into great quality care.

Whilst this is true at its core, it is not attractive as a primary descriptor of CCGs.  It turns the CCG into an organisation that is then a middle layer of bureaucracy.  The government give the money to the CCG, who in turn give the money to the hospital.  What is the point?  Why doesn’t the government just give the money directly to the hospital, and save the millions of pounds it spends on CCGs?

We need to clearly articulate the value-add to that middle step that CCGs bring.  This is the key.  CCGs are made up GPs and GP practices.  They are membership organisations, with GP practices as their members.  So for a start this means that it is clinicians who are deciding how the NHS money is spent.  Not only is it clinicians, it is GPs.  90% of all healthcare contacts in the NHS are with GPs.  No-one understands the healthcare needs of a population served by a GP practice better than the GPs working in that practice.

Second, GPs in CCGs don’t simply decide how NHS money should be spent.  They work with doctors and nurses and other clinicians to design and implement new ways of working that will improve outcomes and the quality of care that is received.  So for example most GPs that I know are using the CCG to change the provision of services for people who want to die at home.  GPs know that most if their patients want to die at home with those closest to them around them, in an environment they feel safe and secure in.  GPs in CCGs are working with clinicians from hospices, hospitals, district nursing services and the voluntary sector to put the services in place to ensure that this is possible.

So what is our elevator pitch?  I think it goes along these lines.  CCG’s (Clinical Commissioning Groups) are groups of GP practices that decide how the NHS money is used in a way that means their local population is as healthy as possible and receives high quality care when they need it.  They use their understanding of their own patients, and their relationships with doctors, nurses and other healthcare professionals, to buy (‘commission’) the services that best meet their patients’ needs.  Because clinicians rather than managers are in charge, the NHS is safe in their hands.

I tried this with my friend.  He could understand what a CCG was.  His problem was that he had never heard of a CCG.  As a group it is critical that CCGs are not anonymous in the way that PCTs were.  We must use the trusted voice of the GP so that CCGs find their way into the public consciousness.  And we must collectively find a way of describing ourselves that is both easy to understand and that is consistent.

If you have a better alternative we would love to hear it – leave a comment, or send it to us at mail@ccginformation.com.