Archive

Archive for the ‘CCG Issues’ Category

Oct
05

When I was 31 I went to see my GP about a mole on my right leg.  I had never met my GP before.  He looked at it, mumbled something about not worrying, but said you can never be too sure with these things and referred me to the hospital.  I never met that GP again.

A couple of weeks later I sat for 3 hours in a corridor in St John’s Institute for Dermatology at St Thomas’ Hospital.  Eventually my name was called, and I entered a large room with a consultant and 8 medical students.  The consultant largely addressed the students, who took it in turns to inspect and touch my mole.  Finally the consultant turned to me and said that it would be better to take it off and check for anything suspicious (we weren’t using the ‘c’ word at this point).

To receive the results of the biopsy I was to see the plastic surgeon.  I had done my research and, without being explicitly told, knew that a cancer diagnosis was on the cards.  If it was, it was all about the ‘Breslow thickness’.  Essentially the thinner the better.  I arrived, nervous.  An hour passed.  A second hour passed, and then a glimpse of the consultant as he left the clinic.  Half an hour later he returned, eating a sandwich.  A further hour later I was called.

‘Well it is what we thought it might be’, he started.  My heart jumped into my mouth.  What’s the thickness??  He told me.  Panic.  At first I thought he had said 3.3mm (5 year survival 60%-75%). But he hadn’t, it was 0.33mm (5 year survival virtually 100%). And breathe…

A week later I arrived at theatre reception for my surgery (I was having a skin flap) at 7.30am, as instructed in my letter.  The door was locked.  I banged on the door and eventually someone answered, annoyed.  ‘I am here for my operation’.  ‘Well we don’t open until 8am, so can you come back then?’.  ‘But the letter told me to be at here at 7.30?’.  ‘That’s because patients are always late’.

I hadn’t slept in a dormitory since I left school, and as I recovered from my operation I reflected that I didn’t much care for it now either.  The surgeon (different from the one who had given me the diagnosis) was keen to protect ‘his’ wound, and wanted me to stay over the weekend.  It was only by threatening to self-discharge that I managed to get out.

When the cast was removed the hospital told me to get the dressings I needed from my GP.  I rang the practice who insisted that I come in to receive the dressings.  I told them I couldn’t walk.  They told me that unfortunately those were the rules.  A friend ended up buying them for me from the local pharmacy.

For three years I went back to St John’s Institute for regular follow ups.  Each time I went I saw a different doctor, and would have to begin by explaining what had happened to me, while they furiously flicked through my notes to try and work it out for themselves.  Eventually I was told follow ups were no longer needed, but if I had any concerns to come straight back.  I am not sure even now whether I can call the hospital direct or need to go to my GP first.

In many ways the NHS provided me with great care.  I have been completely cured, I have a very tidy scar, and I have learnt which moles I need to worry about and which I don’t.  But at no point did I ever feel that the NHS was looking after me.  I was navigating my way through a system designed to serve itself rather than my needs.

A few years ago I bought a car.  I walked into the Audi showroom and was given a cup of coffee while I waited.  10 minutes later I was with one of the staff, a young man called Matthew.  I know he is called Matthew because from that point on he navigated me through choosing the model I wanted, arranging finance, and taking delivery.  He rings me every 6 months to check that I am happy with the car, and to see if there is anything else that I need.  Any problems he sorts out straight away.

For me it is not ok that the experience of buying a car is better than the experience of being treated for cancer.  The world around the NHS is changing.  Businesses work hard to ensure that what they do is built around the needs of the customer.  But in the NHS we are still lost in organising care around the needs of organisations and professional groups.  It has to change.

The HSJ reported criticism of the plans of CCGs to commission pathways of care for single clinical specialties.  The argument against is twofold.  First that focussing on a single specialty will reduce operational efficiencies, and second that patients often have more than one condition, and so focussing on a single specialty is not patient centred.  I fundamentally disagree.

The notion that commissioning whole pathways of care will reduce operational efficiency is based on the premise of ‘carve out’, which simply put is that if you take a lane on the motorway and make it a bus lane, the overall journey time for everyone goes up.  But of course what we are talking about doing here is creating roads that do not exist, roads that start with a visit to the GP and include diagnosis, treatment and follow up.  We must have a service designed around the needs of patients not the needs of organisations.

I know I was lucky because I only had one condition, and was not having to manage multiple conditions at the same time.  But the argument that organising care by pathways is not patient centred because patients often have multiple conditions massively overstates the effectiveness of the existing system, and totally underplays the fundamental shift to patient centred care that commissioning pathways of care rather than organisations represents.

I was not a mole, a biopsy, an operation, an inpatient, or a follow up.  I was a person with cancer.  But that was how the NHS treated me.  It has to change.  Commissioning pathways of care is not the end but the start of this journey.  Whatever the resistance, and whatever the complexities of implementation, it is the right path to be on, and one that CCGs must vigorously pursue.

Sep
30

Michael Porter and Thomas Lee have published an article in the October 2013 edition of the Harvard Business review, entitled ‘The Strategy that will Fix Health Care’.  You can find it here.  Or alternatively you can read this relatively short post and I will tell you what it says!

It starts with the premise that there needs to be a ‘transformation to value-based health care’.  This is essentially a shift in the focus of health care delivery from value and profitability of services provided to the patient outcomes that are achieved.  This transformation, it claims, is on its way,

There is no longer any doubt about how to increase the value of health care.  The question is, which organisations will lead the way and how quickly can others follow.

Some in the NHS understand this.  The development of the Outcomes Framework is a good example of a simplistic attempt to shift the system with one golden bullet.  Many, however, do not, hence the reason the Outcomes Framework has been largely ignored despite its stated importance.  What is clear is that achieving this shift is far easier to say than to do in practice.

So how will this be achieved?  Step one, according to Porter and Lee is to define a proper goal for the health care system.  To improve outcomes for patients.  Not increase volumes or improve margins, just to improve outcomes for patients.  We say we have set this goal in the NHS but of course we have not.  We understand it is breaking even, achieving the 4 hour and 18 week targets, and becoming Foundation Trusts that is really important.

The strategic agenda for moving to a high value health care delivery system has 6 components, which are interdependent and mutually enforcing.

The first is to organise into what the authors describe as Integrated Practice Units.  These units are responsible for the full care pathway of a patient’s condition, not just the individual pieces of it.  These are clinicians and managers working together to provide every aspect of care for a given disease, such as diabetes.

The second is to measure outcomes and costs for every patient.  The outcomes must be those that actually matter to the patient, and be by condition such as diabetes, not by specialty such as podiatry or intervention (eye examination).

The third is to move to bundled payments for care cycles.  Specifically this is neither global capitation not fee for service (the mechanisms generally used in the NHS) as neither reward improvements in outcomes for patients.  This would mean a full care cycle for an acute condition; a year of care for a long term condition; or primary and preventive care for a specific population e.g. children.

The fourth is to integrate care delivery systems.  I like the authors’ description of integrated care, as it has a substance commonly lacking in NHS expositions of the topic.  They comment that most multi-site organisations are not true integrated delivery systems but loose confederations of largely stand-alone services that often duplicate each other.  True integration, they say requires 4 choices:

I.            Define the scope of the services, i.e. only deliver those services where you can genuinely deliver high value for patients

II.            Concentrate volume in fewer locations, because volumes matter for outcomes

III.            Choose the right location for each service line, i.e. deliver the routine and less complex out of hospital

IV.            Integrate care for patients across locations.  The integrated practice units should operate across locations if necessary.

Even the authors note that the politics of this is daunting, as many of us in the NHS have already discovered!

The fifth is to expand geographic reach.  The time has come to end the delivery of health care as a local model only, and allow superior providers for particular conditions to be able to serve a wider population.  This would either be a hub and spoke model, where a provider creates satellite facilities for the relevant integrated practice unit and fully employs, trains and rotates staff through the parent organisation.  The alternative is a clinical affiliation where the integrated practice unit provider partners with community or local providers and uses their facilities and staff, but applies its own successful approach.

The sixth and final component is to build an enabling IT platform (these keep getting easier…).  This IT platform would be centred on patients, use common data definitions, make medical records accessible to all, have templates and systems for each condition, and information would be easy to extract.  Simples.

There is a lot in the article and I am sure I have not done it justice, so I would encourage you to read it for yourself.  While much of what is suggested is both complex and daunting, there is nothing that I would obviously disagree with.  Equally there is very little that could be easily done tomorrow.

As leaders in and of the NHS the starting point has to be an acceptance of the basic premise of the article, that the focus of health care delivery must become solely about improving outcomes for patients.  We need to be less protective of the NHS that we have today, and engage our patients, our public and our staff in a conversation about the need for change so that we can serve them better, and so that some of the changes suggested can move from the theoretical and aspirational, to being realistic and implementable.

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Aug
26

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.

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May
05

Norman Lamb, the care services minister told the HSJ this week that the Department of Health is considering the future use of the 2%  of CCGs’ budgets which we are required to ring-fence from routine spending.  His proposal is that this should be used to fund integration with council run social care services.

The principle behind the 2% is that this funding is needed to enable the system to drive transformational change.  This is needed if we are to have any chance of dealing with the pressures of the next 5-10 years.  Whilst there is a compelling logic to this, it also requires a reality check.

Clinical Commissioning Groups (CCGs) are at present coming to terms with the reality of the inheritance that the historic NHS system has bequeathed to them.  It is not the balanced budget that was promised when the White Paper was first produced.

Many PCT finance directors managed their budgets by putting as little as possible into the acute commissioning lines, to put as much pressure as possible within the organisation onto that part of the system which represented the biggest financial risk, and then balanced the books by using reserves and underspends from elsewhere at the end of the year.  Allocations to CCGs were based on PCT budgets not historic expenditure, and as such many CCGs are now discovering that their allocation brings with it a significant underlying deficit.

Other CCGs are being asked to bail out the specialist commissioners, who equally feel that insufficient funding has been passed to them.  Some CCGs are even being directly pressured by their Area Teams to take a share of the primary care QIPP requirement.  And all CCGs at some point will be receiving a legacy debt of continuing healthcare claims, which they need to account for.

So the first question is to ask, regardless of the official line of each CCG with the Commissioning Board, is whether the 2% really exists at all.  Do CCGs have any non-recurrent money available for in year investment?  Doubtless some will, but for many it is highly unlikely that the full 2% will be available, and for some there will not be any.

What we have is yet another classic example of policy makers being so distant from the realities of the front line that they create policies based on what they hope is happening rather than what is actually happening.  Promising a non-existent 2% to the council will create such tension in many places that it will decimate not accelerate any prospect of integration.

Attitudes to the 2% vary across the country.  This is a further legacy of the historic system.  In some areas providers view the creation of the 2% transformational fund as a top slice on their budgets, and as such believe they are entitled to their ‘fair share’ of the money.  This has already created real problems for some CCGs in contract negotiations where trusts have been pressing for assurances of additional in year money from the 2%, which as we have seen probably does not even exist.

So how are CCGs who have managed to budget for a non-recurrent transformational fund going to use it?  The big discussion is the extent to which CCGs will use it to accelerate the transformation of primary care.  We have discussed on this site the critical importance of this for CCGs (see ‘What should a CCG Primary Care Strategy look like?’ here).

Some CCGs are shying away from this because of the pressure they are receiving about the 2% from acute providers.  Some are shying away from it because they are worried about the perception that they will be using it to line their own pockets.  But the braver and more progressive CCGs are standing up for what they believe in, that the system needs to change and that change needs to start with primary care, and are putting their money where their mouth is.

Bold decisions are needed by CCGs to break the cycle of ever increasing expenditure on acutes, and to make care closer to home a reality.  CCGs need to be left to drive change locally, and to drive integration locally, without being hamstrung by policy makers making decisions with no basis in reality.

Apr
20

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.

Apr
01

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.

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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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Feb
09

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.

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Dec
30

Now that the distraction of the authorisation process is largely out of the way, CCGs need to ensure they are fully ready to take on their statutory duties from April 1st.  Below are 5 resolutions for CCGs for the New Year:

1. Get rid of any outstanding conditions

While some have fared well through the authorisation process, many CCGs are left with a number of conditions.  It is critical that CCGs do everything in their power to get these conditions removed as quickly as possible.  Life is going to be difficult enough, without having your left arm tied behind your back!

2. Stop tolerating poor quality commissioning support

The majority of CCGs are not being well served by their commissioning support provider.  While CCGs are taking on responsibility for operational and financial delivery, those providing commissioning support are primarily focussed on set up and preparation for 2013/14.  Promises of high quality information tomorrow, and world class contracting teams in the future, are no good to CCGs that have already started the most important contracting round in their short histories.

CCGs have demonstrated remarkable patience with those setting up commissioning support.  It is time for this to end, because it is CCGs that are suffering, and CCGs who are accountable when this support yet again fails to deliver.

3. Build a strong relationship with the Local Area Team (LAT)

The NHS Commissioning Board (NHSCB), whatever our view of it is, is here to stay.  The LATs within the NHSCB need strong successful CCGs, as they are charged with performance managing them.  The relationship that each CCG builds with its local LAT is a pivotal one, and one that will be critical to the future success of both organisations.

If the CCGs and LAT are seen by the providers to be vying for power, both trying to claim system leadership, and to be holding opposing views, then there will be an open door for the providers to play the CCG and LAT off against each other.  A relationship that allows differences to be aired in private but consistency to be demonstrated in public is required to prevent this from happening.

4. Agree a primary care strategy with member practices and the LAT

As we have discussed on this site at length in recent weeks, the success of CCGs and individual GP practices is dependent upon general practice changing.  A new model of general practice that can offer an extended range of services, that drives demand management through the system, and that integrates care around the needs of patients is what is required.  This change needs to be happening now, because without it, CCGs will not be able to deliver the rest of the change that is required.

The lack of clarity about whose responsibility general practice is persists, as the NHSCB tries to get to grips with its direct commissioning role alongside its role performance managing CCGs.  This creates an opportunity for CCGs to direct the LAT into agreeing a strategy for general practice, rather than wait for the NHSCB to develop some unworkable top down directive.  Ultimately the key stakeholders that need to be bought into the strategy are not the LAT but the member practices.

5. Work with other CCGs to share learning and support

Despite the competition between CCGs that the authorisation process created, one of the most valuable assets and sources of support that each CCG has is other CCGs.  CCGs will stand or fall together.  The whole NHS expects CCGs to last 2-3 years before they are replaced with the next iteration.  If CCGs act alone then it is likely that these predictions will come true.  But if CCGs can genuinely learn from each other, help each other, and work together to make clinical commissioning the force it has the potential to be, then there is no reason why CCGs cannot continue to exist for many years to come.

2013 will inevitably be a difficult year for CCGs.  It will start with the press that will come from the conditions that many of the CCGs in later waves have already been allocated.  Any end of year trouble will be picked up as lack of readiness by the CCGs to take on their statutory responsibilities from April.  Inevitably there will be transition issues, and as  PCTs no longer exist this can only come back to bite CCGs.  And the financial challenges facing the NHS will continue to increase.

But 2013 will also be the year when the shackles that have been placed around CCGs are finally removed, and where clinical commissioning can come into its own.  It is the time to demonstrate to all that clinicians leading decision making will drive improvements in outcomes and quality of care.  It will be the start of the journey to form a partnership with the public as to the shape of health care in the future.  Good luck with the challenges that lie ahead, and a very happy new year!

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Sep
23

Local Medical Committees (LMCs) were well known for putting in freedom of information requests to PCTs, to find out how much NHS resource had been ‘wasted’ on overpriced management consultancies.  The level of antibodies that exist across large parts of primary care to Mckinsey and their ilk raises an important question for Clinical Commissioning Group (CCG) governing bodies to consider: should CCGs use management consultancies?

There are good reasons for CCGs to take a stance that many LMCs would undoubtedly support and never use management consultants.  CCGs are membership organisations, and if the members do not want management consultants to be used, then they should not be.  CCGs are also striving hard to differentiate themselves from their predecessor PCTs, and this stance is one that visibly enables them to be different.

The real power of CCGs comes from the active engagement and participation of front line clinicians.  Those CCGs that find ways of engaging each and every GP within the group are the ones that give themselves the greatest chance of success.  Part of this is that the engine for change in CCGs shifts from the ‘ivory towers’ that PCT management teams used to drive decision making from, to the interaction of individual GPs with their patients, and the genuine understanding of the changes that are needed that this brings.  CCGs that choose to drive their thinking through management consultants risk doing this at the expense of the engagement of front line clinicians, and for many this is not going to be a risk worth taking.

CCGs also need to find ways of operating with a much reduced management allowance than that which funded PCTs.  One obvious way of doing this is reducing or eliminating the spend on management consultants, which in turn will allow funds to be used for the permanent management capacity that is required to drive sustainable long term change.

There is an argument, however, for using management consultants in very specific sets of circumstances.  One is when there are very new, inexperienced management teams in place, which is currently the case for many CCGs. These teams can benefit greatly from the additional expert support that management consultants can bring in this early stage of their development.  It is notable that many CCGs have actively engaged management consultancies as an ‘organisational development’ partner in the pre-authorisation period.

If you ask the PCT chief executives who regularly employed management consultants, they would say that these companies bring an ability to accelerate and challenge organisational thinking or specific pieces of work, where the ability to do so did not exist within the management team.  For example, where 3-5 year strategies were being developed (something that would by definition be carried out infrequently), they would say it is better to use expert, time limited external capacity, than to try and develop that expertise internally.

Management consultants can also operate as relatively neutral brokers to support and develop multi-organisational working.  So if CCGs are looking to create a system-wide programme on the frail elderly for example, support from management consultancies can create the capacity required to drive it forward quickly, as well as create a requirement for financial commitment from all partners that in turn can lead to greater emotional commitment to the work.  CCGs are also trying to find ways of working with each other, for example so that they can present one voice to their commissioning support provider.  A neutral broker can facilitate this process by bringing an impartial perspective, where leadership by one CCG is often met with mistrust by the others.

So there may be good reasons for CCGs to use management consultants in specific sets of circumstances.  To be clear, these would not include: creating extra capacity (as opposed to expertise) only, as this is far too an expensive a mechanism; looking for external thinking as a substitute for front line clinical engagement; or, worse, because the accountable officer does not trust the judgement of his/her own management team.

Where CCGs do choose to use management consultants, it is critical they have strategies in place for managing the grass root GP antibodies that will exist.  These strategies should consist of some combination of these basic elements:

1. GP leaders not management leaders should lead the procurement process (demonstrating the organisation is still clinically led)

2. GP leaders should be able to clearly articulate the rationale for using management consultants

3. An upfront communication should be in place with the membership about what is happening and why

Management consultants are not evil, and there are occasions when they can add real value. The challenge for CCG leaders is to find ways of accessing this expertise when it is needed, without losing the engagement of the member GPs.  However good the expertise, this is never a price worth paying.

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