Archive for April, 2013


As most of us are feeling our way into the new system, the NHS Commissioning Board decided to enter with a bang, by renaming itself NHS England. Affirmation from the start, it would seem, that the heralded freedoms for CCGs will not be as promised.

On the face of it, a name is just a name. The rationale given for the change is that it makes it clearer and less technical, and enables it to connect more effectively with the public.

I am not so sure. The name ‘NHS Commissioning Board’ makes it clear that the primary purpose of the organisation is commissioning. It signals the difference between commissioning and providing, as the basis for the new architecture of the NHS. If the majority of the public do not know what commissioning is, then surely the existence of a high profile NHS Commissioning Board was an opportunity to address that.

Instead the name NHS England implies the whole of the NHS in England. It does not distinguish between provision and commissioning. Even Jeremy Hunt in his letter to Malcolm Grant felt it necessary to state that, ‘it does not mean that NHS England will now become the headquarters of the NHS in England’. Necessary because that is indeed what the name implies.

Why does this matter to CCGs? It matters because of what it signals, which is that NHS England does not see its role as enabling clinically led CCGs to drive local change, but sees itself as system leader driving whole scale system change from on high. Bill McCarthy, NHS England Policy Director, said in an interview with the HSJ that after 2015 there would be a programme of ambitious and radical service change led by its area teams.

He says, ‘We are all one organisation, and the benefit of NHS England happens locally. That’s where we’re improving outcomes for patients, engaging the public, and collaborating with local authorities and other partners’. Really. I thought that the point of CCGs was for local clinicians to drive local change according to local need.

CCGs have a critical role as local system leaders. They must not give this up simply because NHS England wants to take it on. There is no track record of top down, management led service changes being successful. CCGs need to brave enough to push back, and show that despite what David Nicholson believes, they are correct in their belief that local clinicians are the only ones that ultimately will be able to drive and deliver local change that is truly transformational.

NHS England should not be interacting on a regular basis with acute hospitals, aside from their role as specialist commissioners. But talking to colleagues in CCGs up and down the country, this is not a reflection of what is actually happening in many areas. Area Teams regularly go direct to trusts, bypassing CCGs on issues that are clearly the CCG’s responsibility. The job of NHS England is explicitly to support CCGs, but the reality is that at present it regularly undermines CCGs and is not doing what it should be to make the new system a success.

NHS England has to let go. Local clinicians and local communities have to take responsibility for themselves. Directive behavior from above does create a disempowered, negative culture. The role of NHS England has to become more coaching and empowering. The change of name is a clear signal that this is not its intention, and that is why it is such bad news for CCGs.

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The final guidance on the quality premium is now out.  You would however be hard pressed to notice, as there has been little or no reaction to the release, despite the uproar that followed the presentation of the idea in the White Paper.

The initial framing of the quality premium was as a bonus payment for member practices of CCGs that achieved significant quality improvements.  There is an inherent logic to creating direct incentives for members of membership organisations where members are coerced into joining, but it became one of the more contentious parts of the reforms because of the potential for conflicts of interest and personal benefit. 

Unsurprisingly, and as with most things, the initial ambition was watered down.  In January Pulse reported that CCGs would not be able to hand quality premium payments to GP practices as a ‘bonus’ and will have to ensure that it is used to develop programmes that directly benefit patients.

The final guidance reinforced this view.  It says, ‘Under the regulations, CCGs must use the funding awarded to them under the quality premium in ways that improve quality of care or health outcomes and/or reduce health inequalities.  CCGs will have to publish details of how they spend quality premium payments, so that they are accountable to the public and the local community’ (Quality Premium: 2013/14 Guidance for CCGs, p16).

The reaction to this has been almost overwhelming silence.  There is very little difference from the draft guidance issued in December and the final guidance apart from this paragraph.  As an aside, the NHS Commissioning Board was clearly berated for not including any mental health indicators so the only other change is that they have added statements that they would ‘strongly support’ any local indicator that includes mental health, and that, ‘progress in reducing emergency admissions is likely to need a strong focus on improving the physical health of people with mental health conditions’.

So what are CCGs to make of all of this? It raises a set of questions each CCG now has to answer.  The two that stand out are what priority should the CCG give to the quality premium, and should the quality premium in fact be used as an incentive to drive delivery at member practice level? These need to be answered now, because waiting six month means any potential incentive benefit will be lost.

 The starting point is for the CCG to assess what the real level of potential reward is.  The reality is CCGs will not be receiving £5 per head of population.  If the CCG gets beyond the first hurdles of achieving financial balance and the CQC not finding any serious breaches of quality in the local providers (either of which disqualifies the CCG from any payment), there are multiple ways of the total being reduced.  The one that stands out is that a single case of MRSA will result in a 12.5% reduction.

Even in the worked example in the guidance the CCG with a population of 160,000, which could potentially earn £800,000, only ended up with £300,000.  It does seem that this level of return (closer to £2 per patient) is what will be more realistically achieved by those CCGs that meet the qualifying criteria.

Even so this is not to be sniffed at, and I still think it is worth CCGs driving hard to maximise the return against it.  The money received next year is on top of the commissioning budget and the management allowance.  I don’t think CCGs have a choice but to give it a high priority and take it very seriously indeed.

Some have expressed concern that it might distract from other priorities.  The reality is that it broadly captures many of the things that a CCG needs to be achieving anyway, so I am not convinced this is a real concern.

The second, and probably more interesting, question is the extent to which the quality premium can be used to incentivise delivery at practice level.  It is noticeable that there is so little guidance on how the quality premium can be used (54 words).  It does not say that CCGs cannot distribute all of the funds down to individual practice level, for example on receipt of a plan as to how the practice will improve quality of care or health outcomes and/or reduce health inequalities for their practice population.

Many CCG leaders will feel under pressure from their members to go down this route.  As primary care faces up to the financial challenges of the new contract, and when CCGs are expecting much from their member practices, many GPs will expect their CCG to find a creative way of using the quality premium to incentivise practice performance through the year.

This, of course, is a media story waiting to happen.  In a way the NHS Commissioning Board has swerved the real issue of the quality premium, by essentially letting CCGs decide how to use the money.  The story will doubtless reignite in early 2014 with CCGs as the culprits once the first CCG decides to channel the money into primary care.

My view, for what it’s worth, is that the success of CCGs depends on the engagement, active involvement and transformation of primary care.  This is what will enable care for patients to be transformed, and step changes in quality outcomes to be delivered.  If CCGs can find a way of using the quality premium to achieve this then they should be brave enough to make it happen.   Those CCGs who want to pursue this should work together, because there is a huge mountain climb to make this happen and keep reputations intact.


The biggest criticism GPs level at their CCG faces is that it has ‘become the PCT’.  GP practices have engaged with CCGs on the basis that things will be different, and that the unilateral decision making of the past will not be a feature of the future.

This presents a real challenge for CCGs.  The pressure for action and for quick decisions from the Commissioning Board and from acute trusts and other organisations make it difficult for CCG leaders to be constantly saying that they will check with their practices and get back to you.

The challenge is to get the right balance between the leadership making decisions quickly, and taking time to engage with practices when decisions need to be made.  If a CCG leadership team get this balance wrong, they will quickly find out about it.  Either the member practices will accuse them of acting like the PCT, or partner organisations will claim they are slow and unresponsive.

The larger the CCG the harder this challenge becomes, because it is harder to get the views of so many practices in a short space of time.  This risks practices becoming disenfranchised and the engagement that is so critical to CCG success dissipating.

So what steps can CCGs take to meet this challenge?  The first is to ensure there is high visibility of the leadership team by the practices, in particular the Accountable Officer (and Clinical Chair if the Accountable Officer is a manager).  If practices are confident that the leadership understand where they are coming from they are much happier for decisions to be made on their behalf.  Dissatisfaction arises when decisions are made that are not explained and seem to take no account of what these decisions mean for practices and their patients.

The second step is to ensure that there is an explicit understanding of which decisions need direct practice involvement.  The reality is that it is not possible (or desirable) to involve every practice in every decision.  But this does not mean that they should not be involved in any.  CCGs must have mechanisms for identifying which decisions require all practices to be involved, and then for acting on this.

This is particularly important for the most contentious decisions, which will often be the decisions that directly impact upon primary care.  CCGs need an extremely transparent and fair process that engages practices, but does not just involve GPs, when making decisions that impact upon primary care income.  These include decisions on local enhanced services, on how the quality premium will be used, on any practice incentive scheme, and to a lesser extent on any support linked to delivery of the QOF commissioning indicators.

It is also worth CCGs considering having something akin to a ‘management allowance committee’ that oversees how the £25 per head is used, that creates a transparency with the member practices.  When practices feel that the CCG is using the management allowance in ways they do not understand a divide can quickly develop between the practices and the CCG.

The third step is to ensure that when a decision has been identified that requires input from all practices, that there is a mechanism for making this happen.  This cannot always be that the discussion goes to a set of once a month locality meetings and then be brought back to a further joint meeting.  Whilst sometimes this will be appropriate, taking 6 weeks or more to make a decision is simply too long.  Virtual mechanisms need to be put in place that are effective, that can operate alongside face to face meetings.

The final step is to continually review the processes that the CCG has in place.  Getting the balance right is almost impossible to achieve, so working out whether it is speed of decision making or practice engagement that is suffering will be a quick guide to how things need to change.  For CCGs to be different, and to be clinically led organisations that have genuine practice engagement, they must strive to rise to this challenge.



I met with a CCG Director recently after he had just had his latest difficult meeting with the Area Team of the NHS Commissioning Board.  He was reflecting that the CCG needed to spend less time having cups of coffee ‘engaging’ GPs and more time on actual delivery, and was asking my advice.

Engagement is often seen as soft and an optional extra by performance managers.  Delivery on the other hand is seen as being about tough conversations and telling people what they should be doing. 

This presents an interesting challenge for Clinical Commissioning Groups (CCGs) as membership organisations.  Should CCG leaders be having tough performance conversations with member practices, or should they be spending time engaging practices with the work the CCG is doing?  Has the time come to stop trying to persuade GP practices of the need to be engaged, and to start taking a more directive approach?

It is worth clarifying exactly what we mean by delivery.  CCGs need GPs to ‘deliver’ in a range of different ways.  There is controlling referrals, often by agreeing to some form of practice-wide review of all referrals.  There is controlling prescribing costs by ensuring that cost-effective medicines are being prescribed.  There is the use of referral criteria for certain conditions and procedures, particularly where they fall into the ‘right care’ category.  This can involve telling patients that the pain in their knee or hip is not yet bad enough for them to warrant the risks of a surgical procedure.  It also means participating in the various schemes that the CCG has running, such as daily rounds of all the patients in the local care home, or working with the local school nurse to avoid children being sent to A&E.

This work is not contractual.  GPs are taking this on because they are part of the CCG.  There may be local incentive schemes in place, but rarely will these cover the costs of the time involved.  Plus they are generally paid on results rather than inputs, which is never attractive for GPs.  Equally, for CCGs to be successful, participation in this work cannot be like a local enhanced service (LES) where each practice makes an individual decision as to whether the reward is worth the effort involved.  The CCG needs every practice to fully participate.

CCGs have very limited contractual control over their member practices.  Recent history, and any sensible review of PCTs, demonstrates that using contractual controls to drive GP practice delivery does not work.  The very notion of a distant organisation telling practices what they have to do is a fast track to CCGs picking up the criticism that they are ‘just like the PCT’.

The strength of CCGs lies in their ability to drive delivery through engagement in a common goal across member practices.  It lies in the sense of ownership that practices have of the organisation as a whole.  It comes from a shared belief that by working together the practices can make a difference.  It comes from each individual practice feeling that they are part of something bigger.  It comes from being engaged.

Practices do not deliver because the CCG tells them to.  They deliver, and go above and beyond what could reasonably be expected of them, because they are partners with their fellow practices in the CCG.  They do it because they believe that by working together they can make a real difference for patients, not because a distant organisation has told them to.  Ultimately delivery comes because practices are engaged with the work of the CCG.  If they are not engaged they will not deliver.  Simply telling practices that they have to deliver will not help.

It is not just CCGs.  A Gallup study in 2006 looking at data from 24,000 businesses has demonstrated that engagement and delivery are directly correlated: those with the highest engagement scores (top 25%) averaged 18% higher productivity than those with the lowest engagement scores (bottom 25%). 

When CCGs are struggling with delivery it is really important they do not revert to the old behaviours of highly directive performance management.  My response to my colleague was that he should keep faith with what he was doing, and that whatever the views of those in senior roles in the NHS Commissioning Board may be, to be clear that it is engagement that will drive delivery.  He decided to leave the big stick in the PCT drawer and keep going with the coffee.


The main headline in the Sunday Times this week was, ‘GPs’ private firms grab NHS cash’.  It is clearly a story that had been saved up for when CCGs took on their statutory duties.  It is symptomatic of the general pessimism that is surrounding the start of the new system.

And it is not just those outside the NHS.  Sophia Christie, former CEO of NHS Birmingham North and East, writes in the Health Service Journal this week, ‘Will the reforms succeed?  Given their declared aims I suspect they have already failed.  There is not much harnessing of the creativity of the population of GPs that I see.’ (HSJ 28/03/13, p19).

Failure can be a self-fulfilling prophesy.  In large or complex organisations like the NHS it is often a function of perception rather than something that can be demonstrated objectively.  The very language of failure in itself can cause failure.

So as CCGs what do we want?  My view is that as a collective the most important thing is not about how long we last, but whether we make a difference to the NHS.  The NHS needs to change.  In the last couple of years the NHS has been crippled with the inertia of transition.  The big issues have been avoided and delayed, and there has been no real change arguably at a time when it has been most needed.

CCGs are not here to balance the books, or just to keep things going.  We are here to harness clinical energy to drive improvements in health and health outcomes.  We need to take bold decisions.  We need to tackle the big issues that PCTs shied away from in recent years.  We need clinicians to be prepared to take on the politicians, and to fight for the things they know to be right.

GPs know that their own world is busier and more demanding, with less reward.  The same pressure exists in hospitals, and across the whole NHS.  Fundamental change is required in primary care, secondary care, tertiary care, and self care.  It is needed in the way the whole system works. 

The opportunity that CCGs create for GPs is to be able to accelerate the pace of this change.  Year 1 for CCGs must be a year of tough decisions, a year of bold impact, a year of real change.  It must not be about easing into the new world and hoping not to be noticed.  It must be about having the courage to do what is needed to make a lasting, fundamental difference.

CCGs will ultimately not be judged on the way they do things.  Far too much is being written on the internal processes of CCGs. What is important is the difference we make, individually and collectively, to the NHS, to the quality of care that is provided, and to the health of the population.  We have all the ingredients to be successful in this task: clinical leadership, engaged practices, and the control we have been seeking for a long time.  What we need to do now is ignore the critics, start with a bang, and go out all guns blazing.