Archive for the ‘CCG Issues’ Category


Welcome to the Monthly Digest for October 2014.  This month the Reality Bites podcast has really started to take off!  In the podcast, Joe Tibbetts, a healthcare publisher, and I discuss the issues facing the NHS.  This month we have looked at a range of issues including the 5 year forward view and the political parties treating the NHS as political football during conference season.  You can access the podcast here  You can also now subscribe to the podcast on itunes, so that you never miss an episode!

I have also published 5 posts on the ‘Inside Health’ column at this month:

Does the 5 Year Forward View Mean the end of General Practice? – On the surface the 5YFV looks positive for general practice, but on closer inspection it signals a significant threat to general practice as we know it. Can general practice survive?

What Audi Could Teach the NHS about Patient Care – My experience of Cancer, and while the treatment was good I was fighting the system the whole time.  Buying a car, however, was a much better experience!

The US Strategy that could fix UK Healthcare – We need to engage patients, public and staff in a conversation about the need for change so that change can happen and the service we all aspire to can become a reality.

The Bewildering and Counter-Productive World of nhs regulators – The new system of the NHS has its flaws, and nowhere is this more pronounced than in the area of regulation. But it is essential that all concerned collaborate to make the best possible sense of it.

How do we Close the Gap between Health and Healthcare? – The funding crisis in the NHS means we must start a debate on how we can link choices we make to look after our own health with the amount we pay for our healthcare.

Let me know what you think!  You can contact me here, via website or on twitter @ccginsider.



6 new posts have been published on my ‘Inside Health’ column on since the last digest. You can find them here.

Commissioning Support Units Framework: Help or hindrance? – is the forthcoming procurement of commissioning support units (CSUs) likely to be a distraction from the real task which is an improvement in CCG/CSU relationships?

Nice – ‘The Jewel in the NHS crown’ – NICE has to make difficult decisions because there is not enough money in the NHS, and it plays a critical role in making sure we make the most of the money we have. Are we giving it the credit it deserves?

Clinical Commissioning and the NHS Internal Market – Like it or loathe it the NHS has an internal market, and it is the job of CCGs to make this market work in the best interest of patients and taxpayers.

Rationalising Notional Rent Essential to Solving GP Shortage – Lack of decision making about notional rent is stopping the development of general practice dead in its tracks.  Co-commissioning must prioritise unlocking this issue.

GP Conflicts of Interest must be managed and be seen to be managed – Failure to provide real and visible management of GP conflicts of interest following the introduction of co-commissioning could lead to a loss of public confidence in CCGs.

Collaboration in the NHS is more difficult than ever before – the introduction of a plethora of regulators and the minefield of competition regulations means that it is harder than ever before for NHS organisations to collaborate effectively.

Let me know what you think!  You can contact me here, via website or on twitter @ccginsider.

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As some of you are doubtless aware, I have been bemoaning the lack of an NHS podcast for some time.  In the end I was challenged to do something about it, and now (albeit 6 months later!) the first podcast is out.

I am working with Joe Tibbets who is a commentator on the public sector, and who has been bemused by the NHS for a long time.  We are going to have a series of conversations to try and make sense of some of aspects of the NHS, which to the outsider looking in must seem very complex indeed.  Joe has been pretty gentle on me so far, but I suspect he will get tougher as time goes on!

In the first one we have touched on GP conflicts of interest, and had an interesting debate about NICE and its role in a cash-strapped NHS.  The podcast is called Reality Bites, and you can find it by clicking on the link below:

Please let me know what you think.  You can either leave a comment here, on the information daily site, or via twitter where I am @ccginsider.  I am sure it can get much better, and the more you let me know how, the quicker we will get there!

Thanks again for all your support


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Since last time there are 4 new posts, all published on (here):

What is co-commissioning?  – which looks at how in a short space of time co-commissioning of primary care seemed to evolve from delegated budgets to partnership working between CCGs and NHS England.

Out of hours healthcare provision in need of urgent treatment – which suggests that with development of 111, extended primary care hours, and GP streams in A&E departments, the role of out of hours needs to be urgently reviewed.

The Lost Art of Clinical Commissioning – which says that because of procurement processes CCGs are losing their focus on inspiring and empowering clinicians from all specialties to come together to make change happen

Is the Better Care Fund preventing integration rather than promoting it? – concerns about the shift of money from health to social care, evidence about the lack of impact of integrating health and social care commissioning functions, and an overly bureaucratic process mean the potential gains of integration could be lost.

As always, any feedback gratefully received!  You can follow me on twitter @ccginsider, leave a comment here, or leave a comment on

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The closest I have been to death was a few years ago when I was playing golf in France.  I remember the day vividly.  It was a bright, sunny Sunday morning, but the weather was very much in contrast to the way the three of us were feeling, as we struggled to recover from two nights over-indulging in the local red wine.

After the usual frenetic battle to get to the course on time (missed alarm call, rapid check out, the impossible task of finding a golf course in a foreign country armed with only an out of date map and a singular lack of helpful signposting), we finally arrived at the first tee.  But we needn’t have rushed, as the queue was three groups deep, and it was the best part of half an hour before we were on our way.  Our frustration grew.

Even when we got going the pace didn’t pick up.  We had to wait to play every shot, which meant we also got to watch the group in front.  There were two men and a lady, all of whom were French.  The second hole was a par three.  One of the men and the woman hit reasonable tee shots; the second man hit two tee shots into the deep rough, and rather than play a third just picked up his tee and trudged towards the green.  I know the feeling.

When we got to the third tee, the group ahead had already teed off and were in the fairway waiting to play their next shot.  Then all of a sudden one of the men fell to the ground.  He didn’t get up.  We just stood there, staring, not sure what was going on.  Our trance was broken when all of a sudden the woman started haring towards us, screaming in French at the top of her voice.

As she came towards us, I asked if any of us knew CPR.  None of us did.  We weren’t even sure what it stood for (this was before we had the ‘Staying Alive’ adverts, so we didn’t even have that to guide us!).  However, one of my group did speak reasonable French, so we agreed he would ring for an ambulance and then ring the clubhouse for the defibrillator, whilst we would see what we could to help.

When we got there we couldn’t find a pulse, but given none of us had ever looked for one before it didn’t mean he didn’t have one.  We tried the breath and pushing the chest but the man’s body kept making noises and we panicked that we were making it worse.  We decided the best thing to do was to try and find someone who did know CPR, and sprinted round the course like madmen trying to find someone.  Eventually I found a couple who could help and they took over.

In what seemed like an age later, and what in reality was at least half an hour, the paramedics arrived.  They arrived via golf cart, and it was quite a sight: three paramedics on hanging off the cart with another running alongside, all in full uniform, like superheroes coming to save the day. 

But unfortunately it was too late.  Maybe competent help at the outset would have helped him, but by the time the paramedics arrived there was nothing they could do. 

It is easy to look back and try and apportion blame: blame to myself for not learning CPR, blame to the golf club for not having a defibrillator, blame to the French ambulance service for taking so long to respond to such an important call.  But in the end blame doesn’t help.  I think what is important is to try and take the learning and understand what we can do differently.

Recently I came across a Ted Talk by Eli Beer.  He speaks of how he took an experience not dissimilar to mine and set up a community rapid response service in Jerusalem to support the ambulance service.  They take thousands of volunteers who fill the critical gap between the ambulance call and their arrival.  They save people that otherwise would not be saved.  The response time is three minutes.

And it is not a one off.  They have recently started in Panama and Brazil.  It could be set up anywhere.  As he says, ‘We all want to be heroes.  We just need a good idea, motivation and lots of chutzpah, and we could save millions of people that otherwise would not be saved’.

I wish I could have done more to help on that golf course, and I wish a service had been in place that could have responded more quickly.  As our ambulance services struggle to meet their response times, is it time for us in this country to look at this approach, and to turn our aspirations of local integration into something that tangibly saves lives?



How do you create trust?  Is it even realistic to think that organisations that are competing with each other for increasingly scarce resources are going to be able to trust each other enough to allow credible whole system plans to be developed?

Joint working is essential, but the barrier to it often boils down to one of trust.  Do the CCG and council trust each other enough to pool budgets? Do the hospital and the CCG trust each other enough to enter a risk sharing agreement?  Do general practice and community services trust each other enough to build a single staffing model across a locality?

This can become a chicken and egg type scenario: we don’t trust each other enough to have a single health economy plan rather than a set of organisation specific plans, and we can’t develop trust because we are not working together closely enough.  So if trust is the secret ingredient, how do we create it?

Well I don’t claim to know the answer, but I was at a session with the previous NHS Confederation chief Mike Farrar recently and asked him this question.  His answer was so good that I thought it only fair that I share it with you!

He said that there are three ways to create trust.  The first is to agree a shared sense of purpose.  He said that many health systems do not put enough effort into this.  A system plan is produced, it goes to a whole system meeting, and is generally agreed.  What doesn’t happen is a stress testing of the purpose or a putting it under the fire of different scenarios.  Organisations don’t take the aims of proposed whole system plan back to base and work through with their Boards as to how the goals of the system can match with the goals they have set for their organisation.  More effort here, according to Mike, is an essential foundation to building trust across the system.

The second is to establish system wide clarity on the approach to competition or collaboration.  There needs to be a shared understanding as to how this will work across the health economy.  What doesn’t work is asking groups of clinicians from all organisations to work together to design a new model of care, and then the CCG springing a procurement on the providers that is not expected.

This does not mean that the CCG has to say that they will not be putting any services out to tender or that they will be procuring everything.  What it means is that a framework is established so that everyone is clear when services will be procured and when they will be developed through collaboration.  The rules of engagement need to be clear and signed up to by all partners.

The third is to establish who the system arbiter will be.  Given the challenges that all health economies face it is inevitable that there will be issues on which organisations do not agree.  It is not good enough to simply say that decisions will be taken that are in the public interest, because this can often be argued both ways. 

There needs to be agreement as to whether deviation from the collective agreement is ever acceptable, and if so in what set of circumstances.  Systems must establish an agreed point of arbitration, which everyone signs up to before such a situation arises, and which everyone agrees to abide by when a decision is made.

Trust is a critical but elusive ingredient of effective whole system working.  The current environment and the challenges that we face dictate that there is not enough time to spend years building it up, but what I think Mike’s answer has provided is a set of actions that systems can take now to make their 5 year strategies much more likely to deliver.

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What the impact of the Integrated Transformation Fund (ITF) will be is the question at the forefront of most CCG minds.  It is without question a huge challenge for all local health economies.

There are huge cuts to local government over the next few years.  As a result of this there will be significant cuts to social services, which in turn will impact on health.  Seemingly in response to this it has been agreed that the ITF (now apparently named the ‘Better Care Fund’, but let’s stick with ITF for now) will be established.

The ITF is a £3.8bn fund that seeks to pool existing budgets from April 2015 to enable greater integrated working and the transformation of local services.  According to NHS England and the Local Government Association (LGA) guidance a key criterion for its use is to ‘compensate for social care cuts’.

A critical fact here to keep front of mind is that this is not new money.  It works a bit like a visual trick: social care understand they are receiving an extra £3.8bn and health are under the impression that they still have the same money available.  The NHS, after all, has been ‘protected’ from any funding cuts.

So where then does the money come from?  The expectation set by NHS England is that it comes from the expenditure on acute trusts.    There are two routes identified for this.  One is an expectation that there will be further savings. David Nicholson has talked about the requirement for an ‘additional’ 2-3% productivity gains.  So in 2015/16 there will be a requirement for efficiency savings of 6-7% rather than 4%.  You can make your own judgements about how realistic this is.

The second route is through the benefits that integration realises.  The theory is essentially that if health and social care work together and create new models of care that keep people healthy in the community then admissions will go down and delayed transfers of care will be removed.  But this of course sidesteps the starting point for all of this which was cuts to social care.  The money will at best protect the total current expenditure in community health and social care.

So in reality there will be no new capacity to enable the huge savings required of acute trusts.  Instead the new ways of working through integration will be expected to deliver these benefits with no additional capacity.  Herein lies the key problem that the ITF is creating: it is generating expectations of investment in community services that are not real, and using these expectations to justify the requirement for reduced expenditure in acute hospitals.

So how can CCGs respond?  There are probably two tactics available.  The first is to do everything possible to protect health expenditure.  CCGS can use the absolute minimum possible to be part of the fund, insist wherever possible that the funds used come with clearly badged expenditure, and try to limit the damage that this is inevitably creating.  CCGs could make a judgement that based on the experience of other nationally imposed financial constructs (e.g. MRET) that the incentives will not generate the changes expected, and proceed on that basis.

The second is to recognise that the only actual change proposed within the ITF construct is the integration of health and social care, and so to develop a plan that will maximise the impact of integration.  This then take CCGs into questions of scale, on the basis that the more that is integrated, the bigger the potential benefits (whilst at the same time recognising the bigger the potential risks).  The questions then for CCGs are whether they are prepared to commission all of community health and adult social care with local authorities on a whole system basis?  Are they prepared to create a single commissioning function for this that would incorporate planning, quality and contracting?  Or if not how far are they prepared to go?

Difficult choices ahead.  These choices are compounded by the timescale: the draft ITF plan is due to be submitted on the 14th February.  And we are already well into the contracting round for next year.  Acute trusts are quite rightly going to want to know what the plan is for the ITF ahead of any agreement, particularly any two year agreement.  Unfortunately there are not any straightforward solutions.

Merry Christmas to all, and a big thank you for all of your support and encouragement for this blog throughout the year!

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I recently watched a TV debate about smoking and the NHS.  One man was arguing forcefully that it was his right to choose whether he smoked, how much he smoked and what he smoked, and that it was the job of the NHS to provide care for him when he needed it.  In his mind the two were in no way linked and he was irritated by the notion that the NHS might have a role in influencing his behaviour in relation to smoking.

In this country we love the NHS.  In the celebration of Britain at the Olympic opening ceremony the NHS took centre stage.  We are proud of our system because it is available to all, is free at the point of delivery, and is based on clinical need, not ability to pay.  It is our hero, because when we need it, it will do everything it can to save us.

As we consider our future vision for the NHS, the key is not so much understanding what the NHS is, but understanding our relationship with the NHS.  The man in the smoking debate was clear: the NHS for him is something akin to a ‘safety net’, there for him when he needs it.  And this is not an uncommon view.  The current furore over A&E and winter is driven largely by the symbolic importance of A&E as the front line of the safety net that the NHS provides.

Our attachment to the NHS is driven by stories of how the NHS (our hero) saved me/my grandmother/my father/my niece.  These are powerful stories from key moments in our lives.  Regardless of what happens to me or my family I know the NHS will be there for me when I need it, and that is why I will do whatever I can to protect it.  My attachment is built on this metaphor of the safety net, reinforced by powerful, personal stories.

Conversely, prevention does not create the same stories or drive the same level of attachment.  In the same way that a safety engineer that spots an irregularity in an aircraft maintenance check and prevents an accident ever occurring will never be a hero in the same way as the pilot who safely lands a misfiring plane on the Hudson river, so the flu jab will never be a hero in the same way as the hospital that nursed my grandfather back from the brink of death from flu.

And herein lies the problem.  Because our vision for the future of the NHS is one that has prevention as its hero, and that has citizens as active partners with the NHS in improving their own health.

Paul Pholeros has given a great TED talk on ‘Housing for Health’.  You can find the transcript here.  He describes how in 1985 a man called Yami Lester saw that for the aboriginal population of Central Australia 80% of the illnesses walking into clinics were infectious diseases caused by a poor living environment.  They examined the housing conditions of 50,000 Indigenous Australians and found that only 35% had a working shower, only 10% were electrically safe, and only 58% had a working toilet, all primarily due to a lack of routine maintenance.

The Housing for Health project works on toilets, showers and electrical safety, and as a result over 10 years has delivered a 40% reduction in environment related hospital admissions.  I am not doing this story justice here and I would encourage you to read it for yourselves, but the point is that providing great treatment for the infectious diseases was not the answer; rather it was preventing the diseases from occurring.

We are fortunate not to be dealing with the same developing world poverty of the Indigenous Australians in Central Australia.  But if we believe that the role of the NHS is also to improve health in partnership with the population, and not to simply provide a safety net for all, then our work on a 5 year vision for the NHS must start with this as the conversation.

Delivering 5 year plans to improve health will be impossible if we end up fighting a public whose primary goal for the NHS is to defend the safety net and the hero of curative medicine.  We need to create a new hero for the NHS, to build a belief in the power of prevention and partnership, and we need to do this by developing powerful, engaging stories like that given by Paul Pholeros as an antidote to the stories that are shaping our current thinking.

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I predict that the 5 year visions that each local health economy must produce next year will in fact be far from visionary.  Great visions should be memorable, motivating and measurable, and I predict that the majority of those produced will fail all of these tests.  I am confident in my prediction because we are operating in a system that is not designed to produce great visions.

Seth Godin (in ‘The Icarus Deception’) tells the story that when a world class violinist visited the Juillard School in New York to give a speech and a performance, only 15 of the students attended.  But at the same time every practice room was booked solid.  This is because what got the students into the prestigious school was the ability to play music as it is written, to produce the notes and to follow instructions.

The dilemma these student violinists face is that what got them into the school is not going to help them when they leave.  The world is not short of good violin players.  What the world wants is original art: violin players that play music in ways that no one expects.  And this is what the young students have been culturally encouraged to avoid.

The parallel with leaders in the NHS is clear.  The Hay Group survey of the ‘top leaders’ in the NHS demonstrated that the vast majority have pacesetting as a predominant style.  Leaders in the NHS are good at getting things done.  They have become leaders because in the past when they have been asked to make things happen, they have made them happen.

But once they become a leader, following instructions is no longer sufficient.  The job now is to make the rules, not to follow them.  And we have not been trained for this.  There is no ‘what I should be doing’ because there is no ‘should’.  Now leaders must create a vision, develop the rules and make original art.

But the system of the NHS is not designed for this type of leader.  Is the NHS one organisation or multiple organisations?  Does it require one vision or hundreds?  The reforms were designed to shift the responsibility to the bottom.  To take away even the possibility of another ‘NHS Plan’.  So in the absence of a single grand plan each local health economy is asked to produce their own.

But what this means is that the NHS system as a whole should be supporting local leaders to create great visions.  In the new world, in the absence of a single plan, this has to be the priority.  But of course it isn’t.  The system is trying to find new ways to drive conformity and delivery – urgent care, finance, hospital inspections etc.  Leaders need to be immersed in the here and now.  The NHS does not want its leaders spending their time looking at other industries or other healthcare systems in other countries; what it wants is the crisis of the day to be tackled.

So with a set of leaders with no track record of producing great visions, who are busy playing the violin in the practice rooms, and with no support in place for them to produce one now, I am confident that most of the 5 year visions submitted next year will be neither memorable, motivating nor measurable.



The guidance is out.   CCGs and foundation and non-foundation trusts are required to produce a detailed two year plan by March and an agreed 5 year strategy.  Build in to your thinking 4% efficiency targets, a 1.9% tariff deflator and a £3.8bn transfer to social care.  Some challenge.

To be fair the size of this challenge has not gone unrecognised.  The joint letter from NHSE, Monitor, TDA and LGA states that, ‘CCGs, foundation and non-foundation trusts… must develop and implement bold and transformative long-term strategies and plans for their services, otherwise many will become financially unsustainable and the safety and quality of patient care will decline.’ 

A key part of these plans needs to be clear thought and strategic thinking as to the role of hospitals in 5 years’ time.  Somehow CCGs and hospitals have to agree this to create a joined up strategy.  What won’t work is a set of individual plans from hospitals and CCGs that make overly bold savings predictions and lack any vision or strategic thought as to what the future will look like. 

The Nuffield Trust has outlined the consequences of continuing down the road we are currently on.  In their submission to the Health Select Committee earlier this month (here) they warn that the government must think about how to deal with a situation in which hospital trusts start to become unsustainable in larger numbers than the current system is designed to address.  Their research shows no evidence of a step change in productivity which could enable the NHS to be able to do more for less at a rate to stay within the available financial envelope.

But what appears to be lacking is a set of clear options from which local health economies can choose to frame coherent thoughts about the future of hospitals.  There is a real absence of strategic thinking to support the production of these 5 year plans.  And before the writing must come the thinking.

So where do we start?  As good a place as any is an article in the Bulletin of the World Health Organisation (2000) by Martin McKee and Judith Healy, ‘The role of the hospital in a changing environment’ (here).  Despite being written 13 years ago, it still provides a helpful background to the role of the hospital, and highlights the complexities of any efforts to introduce change.  As they put it, ‘Hospitals pose many challenges to those undertaking reform of health care systems. They are, quite literally, immovable structures whose design was set in concrete, usually many years previously. Their configuration often reflects the practice of health care and the patient populations of a bygone era.’

The debate around the future of hospitals tends to centre around the size and configuration of hospitals, as entities in their own right.  To merge or not to merge.  Arguments swirl around improvements in outcomes through increasing specialisation, and greater economies of scale through fewer, bigger hospitals.  Alternatively smaller hospitals produce greater access and reduce inequalities.  The impact of technology is argued both ways.

This debate, however, operates in isolation from reform of the wider system.  And it is not alone in this.  Discussions about the future of general practice equally have an insular focus, without painting any sort of picture of how the system as a whole might operate in the future (as we have previously discussed here).

The most recent discussion on the role of hospitals has come from the Future Hospital Commission of the Royal College of Physicians, when in September it produced, ‘Future Hospital: Caring for Patients’ (here).  Within this there are some interesting recommendations, including:

  • Hospital services to operate across the whole health economy, and for hospitals to be responsible for specialist medical services inside and outside the hospital
  • Care delivered by specialist medical teams in community settings
  • A ‘Clinical Coordination Centre’: an operational command centre operating across the health economy with links to acute, specialist and primary care and community teams

This builds on what was alluded to by Keith Palmer in his 2011 report for the Kings Fund, ‘Reconfiguring Hospital Services: Lessons from South East London’ (here), which states,

Reconfiguration should focus on achieving the best patient outcomes and patient experience for all NHS patients, and on narrowing the quality gap between the best and worst performers. This is best achieved by designing reconfiguration to drive accelerated adoption of best practice models of care in as many services as possible. This in turn is best achieved by designing reconfiguration along patient pathways involving specialist/tertiary hospitals, district general hospitals (DGHs) and primary care providers.’

And if we recall Porter and Lee’s premise in ‘The Strategy that will fix Health care’ (see here) that care needs to be organised into units responsible for the full care pathway of a patient’s condition, then it seems to me that we are left with two real choices in our thinking on the future of hospitals.

The first is that hospitals take the lead on the delivery of pathways across whole systems.  As organisational entities their boundaries are extended as far as primary care, and different hospital  organisations would lead on different pathways (i.e. specialist hospitals would have lead responsibility for more specialist pathways).

The second is that hospital organisations become organisations analogous to shopping centres, whereby they would run the estate and maybe also staff for other organisations that have lead responsibility for pathways, who are able to use the facilities as appropriate.  So just like a shopping centre provides the space and facilities for different retail organisations to use, so hospital organisations could provide theatre and ward space and facilities for care pathway providers.

Clearly this needs thinking through, and I am sure there are other options that I have not thought of.  But what I do think is important is that we make the best possible use of the next 6 months to consider these issues carefully, that we spend some real time collectively thinking in a way that is not constrained by organisational boundaries, and that we produce plans with a vision that we believe is achievable in the tough climate within which we are operating.