Archive for August, 2013


This week it was reported that 9 CCGs are forecasting a deficit at the end of the year.  We don’t know how many other CCGs are also concerned about their financial situation, but I suspect it will be more than a handful.

CCGs need a long term plan.  The announcement by the Chancellor of the Exchequer that there will be real terms growth of 0.1%, a transfer of £3.4bn from NHS to an ‘Integration Transformation Fund’, and a 10% cut to the NHS administration budget, all for 2015/16, mean there are extremely challenging financial challenges ahead for all CCGs, not just this week’s 9.

Creating year on year QIPP plans, with bigger and bigger forecast reductions in A&E attendances and emergency admissions which at the same time insist on relentlessly rising, is not going to work.  It is going to need CCGs to lead major transformations of the health and social care landscape.

So how do we do this?  Historically many PCTs would turn to management consultants.  But this is unlikely to provide the answer,

 ‘A consultant’s report – all thought and little heart, forecasting where you can flourish in 2 or 5 or 10 years, produced by smart outsiders, and acted on in a linear way by a limited number of people – has little or no chance of success in a faster-moving, more uncertain world.’  John Kotter

Or do we just need to face the fact that we are going to have to slash services?  Is it true that the fiscal reality can lead us down no other path?

David Nicholson doesn’t believe that.  In the Call to Action launched in July he said, ‘Too often, the answers are to reduce the offer to patients or charge for services. That is not the ethos of the NHS and I am clear that our future must be about changing, not charging. To do so we must make bold, clinically-led changes to how NHS services are delivered over the next couple of years.’

I agree, and so do the GPs I work with.  The reality is most people know what needs to happen.  Less healthcare more health.  Taking services out of hospital that don’t need to be there.  Empowering people to take care of themselves.  Freeing up NHS services and staff from old style practices and buildings.  Breaking down barriers and joined up working.

There is always resistance to change.  But the challenge is not buy in to what needs to happen, it is buy in to why it needs to happen.

There is a Ted talk by Simon Sinek entitled, ‘How Great Leaders Inspire Action’.  He says that most companies lead with what they do, but the great leaders and companies communicate why they do it.  All members of a company know what they do, some know how they do it, but most don’t know why they do it. 

CCGs have to lead transformational change, at a pace never previously achieved.  But they can do it. They can do it because they are led by local GPs, who have a real passion for the ‘why’.

Dr Jonathan Griffiths is a GP at Swanlow Practice in Winsford, Cheshire, and Chair of NHS Vale Royal CCG.  He says,

As a GP I work in Winsford. I see first hand the medical problems coming through the doors of the surgery. The children with coughs, colds and chicken pox. The teenagers with acne. The couples attending for contraception, maternity services or fertility problems…  It is with this perspective that I have become GP chair of NHS Vale Royal CCG. This is what is different about the NHS landscape now. I am close to the patients, and I am close to the commissioning of services. I can see where the needs are, and I want to make a difference.’ You can read his blog in full here.

The GPs who have taken up leadership positions in CCGs want to make a difference to real people’s lives.  Leading the transformation needed is not an exercise in breaking even.  It is an exercise in making a difference to real people’s lives.

The real challenge for those leading CCGs is relentlessly communicating the ‘why’ – why changes need to happen, why they need to happen quickly, and why real people with real outcomes depend on these changes being made.  Yes they need support, and yes it won’t be easy, but no one can do this better than the local GPs leading their CCGs.



I know the word ‘estates’ can act as a good sedative too many, with its own impenetrable set of terms and acronyms, but we can’t afford to ignore it any longer.

One of the biggest unintended consequences of the reforms is the complete inertia in the development of community and primary care estate. Like it or not, it is down to CCGs to tackle this, because if we don’t it is extremely unlikely anyone else will.

Here’s why. Historic PCT estate strategies primarily focussed on LIFT or other developments whereby the additional revenue costs were to be funded through commissioning savings. By separating out the secondary care commissioning budget from the estates budget, no single organisation can now create this type of business case. So the incentive to develop out of hospital estate has suddenly disappeared from the system.

There are a number of players on the pitch, some more willing than others! And, if you are from a CCG, you are one of them! Let’s look at each of the others.

First, the Area Team. The funding for primary care premises sits within the Area Team budget. It is within their baseline allocation for primary care, meaning that it is not ring-fenced or identifiable. Any new applications for borrowing costs or notional rent for new developments are entirely conditional on the availability of funding within the Area Team baseline.

So any new developments add cost to Area Team budget, without them receiving any additional income in return. Not a surprise then that no drive is forthcoming from Area Teams to develop primary care estate!

What about NHS Property Services? Well their role is confusing. They have taken over the management of previously PCT owned community and primary care estate. Essentially they charge CCGs and Area Teams for managing this estate, so they are estate managers. But they are more than just managers because they also now own this estate. So they have talked about a ‘capital programme’ for estates investment to be rolled out later this year.

But any capital programme will be prioritised on a much bigger footprint than any individual CCG. Contact with CCGs by NHS Property Services remains, at best, minimal. The chances of them driving, or even being able to drive, a local estates strategy that makes sense for the local health economy is zero.

Another key player is the local council. They are responsible for all local developments. If a developer wishes to build new houses, under the Town Planning legislation they have to pay money to offset the costs of the external effects of the development, i.e. the impacts on schools, health, police etc. This is referred to as Section 106 funding.

By effective joint working with the councils, health can ensure that it receives appropriate 106 funding. Conversely, if it does not get involved with new planning applications the opportunities can be lost. Councils have an important support role, but they need the drive to come from health.

There is of course another estates company on the market. Community Health Partnerships (CHP) is a ‘sister’ company to NHS Property Services. It has existed for a number of years and has established 49 LIFT companies, and took over responsibilities for LIFT estate following the abolition of PCTs. To further confuse matters, NHS Property Services supplies estate management and financial services on behalf of CHP (still with me?).

So what of LIFT? Well where one exists, CCGs are better placed than others, not least because LIFTCos are obliged to have a Strategic Service Development Plan (SSDP), which underpins local estate development. Now most commentators believe that it is unlikely there will be any new LIFT developments other than those already in the pipeline.

But maybe the most sensible commentary on the current situation has come from the LIFT Council, which is the trade association for the private equity investors into LIFT schemes. They suggest the development of, ‘Local Estates Forums, modelled perhaps on LIFT’s Strategic Partnering Boards, to enable CCGs, Health and Wellbeing Boards, Local Area Teams, Commissioning Support Units, Local Authorities, LIFTCos and the local outposts of NHS Property Services to map estate needs and plan what is necessary to deliver Joint Strategic Needs Assessments and Local Strategies. These Forums could potentially by formed as a sub-committee of the Health and Wellbeing Boards to ensure that they are locally focussed and led.taken from LIFT Council position paper

I think they are right. They suggest NHS England needs to be the convenor, but I would suggest CCGs get these moving and set them up themselves.

I know many find estates a dry topic, and the complexity of it can feel insurmountable, but the sad truth of the matter is that the CCG voice on estates is currently absent. It is sort of understandable. PCTs had estates people who could drive a PCT view. CCGs, without that expertise, seem to be shying away from the issue, and leaving it in the ‘too difficult’ box.

But CCGs need to be driving this. We are the only ones with the real incentive to do so, and without it, unfortunately, any plans we have to shift activity out of hospital are going to be hit by a lack of brick walls.

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Michael Dixon suggested in Pulse recently that CCGs should directly commission general practice.  So should we?

You can find the article here.  Unsurprisingly the main reaction has been a vigorous waving of the conflicts of interest banner.  This unfortunately distracts from the main question Dr Dixon is trying to address, which is how do we transform general practice.

Dr Dixon’s view is essentially that it is already clear that NHS England, who have responsibility for commissioning general practice, are not going to be able to lead any form of change.  Worse, he says that there has been a hiatus in the development of primary care since NHS England took it over which means GPs are not able to provide the service they want to.

His conclusion is that responsibility for directly commissioning general practice needs to transfer to CCGs.  He says, ‘I now think there’s no longer any alternative, because NHS England are not able to perform on this.  They’re having a great deal of difficulty in covering primary care and there’s not sufficient local sensitivity.   We need much greater fluidity between primary care and CCG budgets. This is holding up a lot of good work that could be done by CCGs.’

So, conflicts of interest to one side, is it true that shifting responsibility for commissioning general practice to CCGs is the best way of accelerating the transformation of general practice?

I am not so sure.  As direct commissioners the majority of effort gets sucked into the minority of very poor performers and outliers, and leaves very little capacity for working with the majority who are under pressure and struggling but keeping below the radar.

On top of that, contractual disputes between practices and CCGs seem to me to be a fast track to a deterioration of relationships, and would stop any real change of general practice dead in its tracks.

The reality is that for these reasons, and probably many others, PCTs, or indeed any predecessor commissioning organisation, were not able to effect a successful transformation of general practice.

For me, a much better model is for CCGs to step up and take a lead role in transforming primary care.  NHS England is not going to stop CCGs, and indeed are enthusiastic to work with CCGs for this to happen.  NHS England fully recognises the capacity constraints it is operating under, and can use its direct commissioning role to provide cover for CCGs who want to lead this change.

Changing general practice will not happen overnight.  As with any change what is important is to get some movement, some traction.  CCGs can use the space of NOT directly commissioning general practice to work those who want to change rather than those who do not to show what is possible and to create some momentum.

There are many practices that want to change but don’t really know how to do it.  That is where we should be focussing our efforts.  We don’t need to directly commission these practices to help them to change.   We can build change programmes, provide leaders with support, and create communities of the willing.

General practice needs  support to change.  CCGs should let NHS England focus on the really poor performers, giving whatever help is needed, but should use the relationships, the understanding of general practice, and the fact that we are membership organisations to start to make change happen.

CCGs don’t need anything else to transform general practice.  We just need to get on with it.  In the words of Barack Obama,

Change will not come if we wait for some other person or some other time.  We are the ones we’ve been waiting for. We are the change that we seek.


The job description for the new CEO of NHS England is out.  When I look at the way that David Nicholson has been treated by the press, it amazes me that anyone would want the job.  But undoubtedly there will be those that do, so what do CCGs want from the new incumbent?

Well I think there are three key things we would want:

1.  A personal commitment to commissioning

It was distinctly unhelpful that one of the first acts of the NHS Commissioning Board was to rename itself as NHS England.  I discussed why in more detail in this post

David Nicholson himself also questioned the value of the commissioner provider split in an interview with the HSJ in June.  If CCGs are tasked with on the ground commissioning, and NHS England is the national voice of commissioning, CCGs need more commitment from NHS England to the work they are undertaking.  This needs to come directly from the person in charge.

2.  A style that empowers and enables CCGs

NHS England currently has a somewhat schizophrenic relationship with CCGs.  On the one hand it is trying to build a partnership with CCGs through the NHS Commissioning Assembly and other mechanisms.  But on the other it builds more and more complex frameworks to gain assurance from (performance manage) CCGs.

The job description states that the new CEO will, ‘with CCGs, develop a commissioning system which is evidence based, clinically-led and patient centred’.  It even goes on to say that, ‘the success of the NHS system overall relies on achieving excellent working relationships with a wide range of partnership organisations, including: CCGs’.  CCGs recognise they need support.  To deliver the scale of the change that is required at the pace that is needed CCGs desperately need headroom, protection on occasion, and cover.

But currently within NHS England we have one team focussing on how to support the development of CCGs and one on how to performance manage CCGs.  A quarter of CCGs still have conditions from the initial authorisation and a new round of quarterly checkpoints is underway.  Real empowerment does not happen at the same time as this type of performance management.

A genuine commitment to partnering with and empowering CCGs is needed from NHS England, and for this to be really effective it requires a leader whose personal style reflects this.

3.  A belief in the potential of general practice

General practice needs to change.  It needs to change for a whole set of reasons, but the most important is so that the new Chief Executive can, as the job description puts it, ‘deliver more or better quality with less’.  Most health systems cry out for a gatekeeper function.  We have one, but we need to nurture it, modernise it, and reshape it to enable it to meet the challenges we face now and increasingly into the future.

What is important is that the new Chief Executive is not lost in the government’s apparent desire to ‘take on’ the GPs, but that he or she understands that effort in this area is key to system transformation.  We need a Chief Executive who wants to work with CCGs in a genuine partnership to enable general practice to change at the pace that all of us require.

To finish I just want to say a big thank you for all the messages of support I have had since my post last week.  It was great to hear from so many of you, and one of my hopes is that it now we can use the site for more conversations about CCGs, and to discuss how we can work together to support each other and give CCGs the best possible chance of success.