Archive

Archive for March, 2013

Mar
24

As the 1st April 2013 draws ever closer, clinical commissioning groups (CCGs) are getting to grips with exactly what inheritance the PCTs have left them. 

Time will tell exactly how the 2012/13 year ended up, and PCTs will no doubt point to the fact that in the transition it was the embryonic CCGs that were making most of the decisions, but the legacy is not the one originally envisaged when the Health Act was produced.

The promise made to CCGs was that they would not inherit a recurrent deficit.  The reality is that while very few PCTs declared an end of year deficit, many PCTs were either supported directly, or the acute trusts in the PCT patch were supported, either by the SHA or through some other external funding source.  What this means is that the underlying recurrent position that CCGs need to fund in many cases is greater than the funds available.

CCGs should have inherited not just a balanced position, but indeed a 2% fund that can be used non-recurrently (i.e. not already committed in the recurrent position) and a 1% surplus.  If you add in the uncertainty that the shift of funding to specialist commissioners at the NHS Commissioning Board has created, it is fair to say that only an exceptionally small minority of CCGs will be starting the year in this position.

The Everyone Counts framework has mandated that in 2013/14 every CCG must deliver a balanced plan that sets aside 3.5% of its allocation.  Each CCG must deliver a 1% surplus, create a 2% transformational fund for non-recurrent investment, and create a 0.5% contingency.  If you add to this funding of an unbalanced recurrent position, plus any in year growth requirements, the QIPP requirement for many CCGs in year 1 is often between 6 and 7%.

So what are the implications of this?  We all know the state of the economy, and no one is expecting the financial position to be easy.  But many CCGs have a huge challenge to get on top of the finances, and need to be supported in achieving this.  Delivering a QIPP plan of over 6% with the majority of the funding committed in contracts is a very tough ask.  The NHS Commissioning Board (NHSCB) must provide flexibility and support to the CCGs in this position. 

The starting point for this should be flexibility in the application of the financial rules, whether this is flexibility in the 2% (i.e. allowing some of it to fund recurrent expenditure) or relaxing the requirement for the full 1% surplus.  As CCGs get started they need to be allowed to produce robust two year financial plans that return health economies to financial health, and be supported in doing this.

The wider, and more important, implication of this is that it puts the CCGs’ focus primarily on the finances, when as CCGs start out they need to be demonstrating to the public the difference that clinically led commissioning can make to health and outcomes.  If CCGs start off simply being known as the new group introducing an even tougher round of rationing, it may become a shackle that is hard to shake off.

Success for CCGs is not breaking even, or delivering an indefensible surplus back to the treasury.  Success will be the clinicians leading commissioning making a real difference to the lives of the population they serve.  Yes the finances need to be delivered, but the NHSCB must support CCGs to make the difference they have been put in place to deliver.

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Mar
16

The history of Clinical Commissioning Groups (CCGs), short as it is, has conspired to set CCGs up in competition with each other.  At a time when many are already predicting the demise of CCGs, it is critical that CCGs work together to be successful.

So how has this situation come about?  The primary reason is the authorisation process.  This created a competition between CCGs (‘What wave were you in?’, ‘How many conditions do you have?’ etc etc), that is neither helpful now, nor conducive to future success.

This competitiveness stems from the origins of CCGs as self-selected groupings of GP practices.  These groupings often set up around historic alliances and rivalries.  Once practices made a choice as to where their allegiances should lie, they naturally wanted to validate this decision making by demonstrating that ‘their’ CCG was better than the CCG they had chosen not to join.  This has meant that the biggest barriers to joint working exist between neighbouring CCGs with whom the strongest alliances are most important.

Some CCGs have already had to deal with some of these turf wars as different groups have had to come together to form a larger whole.  Making this work internally has taken such effort that building relationships with other CCGs has understandably taken a back seat.

The limited management allowance, and the fact that many GPs are carrying out the commissioning role in 1, 2 0r 3 days per week, mean that the capacity for collaborative working between CCGs has not existed, even when the desire to do so does.  Completing the collaborative agreement template that exists for CCGs remains on the to do list of most CCGs, rather than the tasks completed list.

The time has now come to draw a line under the past and put an end to any competition.  It is incomprehensible that at this stage any one CCG has all the answers.  It is critical that CCGs learn from each other, because ultimately we will succeed or fail as a collective.

CCGs are totally new organisations.  There are sets of issues that CCGs are dealing with that predecessor organisations such as PCTs never had to, such as creating effective governance as a membership organisation of GP practices, developing meaningful and sustainable practice engagement, managing the NHS Commissioning Board, and making commissioning support effective.

So what can we do to learn from each other?  How can we recognise the constraints that we all operate under, and yet create the capacity to learn from and support each other?

The starting point is for CCGs, individually and collectively, to commit to doing this.  It is critical we are active in this, and do not leave it to others (in particular the NHS Commissioning Board) to arrange on our behalf.  We must decide for ourselves what good is, and find ways of sharing and learning that are effective for us.

This website is one opportunity for sharing between CCGs.  One of the most common requests we receive is for case studies on how individual CCGs have successfully met some of the challenges they face.  So here are three things that you personally can do to help the development of collaboration between CCGs:

  1. Request information and advice from other CCGs.  Use this site to pose questions that you want the answers to.
  2. If you or your CCG has a case study of success in any of the categories in the sidebar of this site, send them to us and we will gladly publish them to make them accessible to others.  We have had specific requests for examples of how CCGs have created strong practice engagement, and of where CCGs have developed effective primary care strategies, so if you have examples particularly in either of these areas we would be more than happy to publish them.
  3. Finally, tell other people who work in CCGs about this site.  The more we share and learn together, the stronger we will be!

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Mar
11

There are now only 20 days to go until Clinical Commissioning Groups (CCGs) take on their statutory responsibilities.  It is important that we start with a bang.

As a collective CCGs need to decide whether they are going to take the initiative and ensure they are successful.  Primary Care Trusts (PCTs) appeared to drift in the background hoping not to be noticed (I recognise I am generalising), but at the end of the day the majority of the public could not tell you what a PCT is or does.  We must learn the lessons of our predecessor organisations and take the initiative from the start.

The first 100 days are like a sprint and beyond that more like a marathon.  New organisations need to make an immediate impact, and so a strong, achievable first 100 days plan is vital, whilst also setting the tone for long term success.

The web-based business publication Fresh Business Thinking wrote last year, ‘Dynamic leaders need to divest themselves of the idea that the first 100 days can be considered the ‘honeymoon’ or ‘settling in’ period; those days are long gone.  Judgements are made more quickly now and … achievements in the first 100 days are routinely taken as an indication of (their) leadership potential in the future’.

It may feel to us like we have been around for a long time, but to the NHS and wider public our time is just about to begin.  But get the first 100 days wrong and the CCG obituary may start being written before we know it.

So what should be in the first 100 day plan for a CCG?  Best practice for such a plan is to split it into three sections.  Section one is the first 30 days, which is all about identifying quick wins.

CCGs need a focus on clinical leadership and clinical engagement to drive home the relative advantage CCGs have over predecessor bodies.  So the quick wins need to be real examples of clinicians using commissioning to make a difference for ‘their’ patients.  Even if a CCG has already held a launch event, it is well worth considering another for the takeover of statutory responsibilities.

Section two is the second thirty days which is all about identifying key priorities.  If the first month is about establishing the things we have already done and getting that into the public consciousness, the second month is about communicating the things that we are going to do, and going to do quickly.

Part of this is also about establishing relationships for the future.  CCGs need to put a marker in the sand with the NHS Commissioning Board, most probably with their Area Team.  The relationship has to be shifted out of the parent/child relationship that the authorisation process has created, and moved to the adult/adult relationship promised by David Nicholson.  It is unlikely this will happen unless CCGs are active in shaping it.

Section three is the third 30 days which is about setting out the long-term vision.  So in 100 days CCGs need to have demonstrated that they are making a difference now, that they are tackling the right things, and that they have a plan for the future.

One of the areas for section three is about setting out how CCGs will use commissioning support.  In 20 days time CCGs can be much more bullish with commissioning support providers.  CCGs should lay out their plans for the future in a clear and unambiguous way that signals that the transition period is over and that unmet expectations will not be tolerated.

The first 100 days are important for all CCGs.  Whilst what happens does not guarantee success or failure, it is a time when ‘virtuous cycles’ of increasing credibility and momentum, or ‘vicious cycles’ of diminishing credibility and inertia, get established.  If we want to be successful, we need to be planning hard now to ensure we start off as we mean to go on.

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Mar
04

What is the role of the GP Chair?  While it seems a straightforward question, it is becoming clear that it is one that is fraught with complexity.

Many CCGs have set themselves up with a GP as Chair, and a manager as Accountable Officer.  Some reports indicate that this arrangement is in place in up to 80% of CCGs.  Detractors of CCGs regard this as evidence of lack of GP engagement in commissioning, but in reality it is simply an acknowledgement of where the relevant skills lie.

But it is not a straightforward arrangment.  Is the role of GP Chair an executive role or a non-executive role?  The guidance is ambiguous.  It starts with all the expected attributes of a non-executive chair (e.g. ‘ensure that the CCG has proper constituional and governance arrangments in place’, ‘ensure that the Governing Body is able to account to local patients, stakeholders and the NHS Commissioning Board’).  However it goes on to state, ‘All CCGs will need to identify their senior clinical voice for interactions with stakeholders, especially the NHS Commissioning Board.  This senior clinician will have a place on the CCG assembly.  In many cases, this will be the Chair of the Governing Body.’

So the role of the GP Chair is primarily non-executive, yet is also expected to be the ‘clinical voice’ of the CCG.  The reforms expect to hear a clinical voice not a non-clinical voice (regardless of who is accountable), and this pushes the GP Chair into taking on the role traditionally undertaken in NHS organisations by the Medical Director.

So is the GP Chair part of the executive management team?  Does he/she attend management team meetings?  If so who chairs these meetings, the Accountable Officer or GP Chair?

A common scenario is that the GP Chair chairs the Governing Body, and the Accountable Officer chairs the management team meetings, but with the GP Chair in attendance.  Naturally, the GP Chair takes on responsibility for those issues a Medical Director (conspicuous by their absence on CCG Governing Bodies) would normally take, such as CCG-wide clinical issues.

But this in itself is problematic.  How can the GP Chair hold the Accountable officer and management team to account at the Governing Body is he himself is part of the management team?

If the GP Chair is getting sucked into the operational detail of the day to day functioning of the CCG, where do they find the time to develop the Governing Body as a unit, and to manage outwards as the ‘clinical face’ of the CCG?  The reality is, they cannot do both.

We have identified 5 potential pitfalls for GP Chairs already (here). The role is complex, and for the majority of new GPs requires a totally new skillset to the one they thought they needed for the job.

The job is not to be the Accountable Officer by proxy.  It is not to have an individual right of veto on all decisions made by the management team. It is not to be the Medical Director.

The job is however to ensure that the organisation is and remains clinically led, and to hold the management team to account for that.  It is to manage external stakeholders as the clinical voice of the CCG.  And it is to ensure that the Governing Body is effective.

The reality is that to fulfil the requirements of the role effectively, GP Chairs should not be part of the management team.  Yes there needs to be a close and effective relationship and strong communication with the Accountable Officer, but there also needs to be distance.  It is hard for GPs to ‘let go’ and take the strategic view, but this is what is required.  The role is non-executive.

At present no-one is writing about this, but CCGs need to be sharing their experiences and learning journeys with each other about tough internal issues such as this in order to be effective.  If you want to share your experience contact us at mail@ccginformation.com.