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Archive for the ‘CCGs and NHS England’ Category

Jan
01

Reading the planning guidance is always a treat(!), so it was very festive of NHS England to release this year’s guidance on Christmas Eve as a seasonal gift for CCGs and organisations across the NHS. 

It is a confusing time to be in the NHS.  We are so used to there being a plan dictated from above, and of taking on the job locally of putting this into place, that it can be quite disconcerting to receive guidance that reinforces that there is no overall plan for the NHS.  In the old days we received the ‘operating framework’, which described what local organisations needed to do to within the overall plan for the NHS.  We now have guidance ‘that sets out the need for bold and ambitious 5 year strategic plans’

It does claim to also ‘describe an approach to deliver transformational change’.  There is (inevitably) a framework (‘5 outcome domains with measurable ambitions, and three further measures of improving health, reducing health inequalities, and moving towards parity of esteem’), and then this strange concoction of ‘characteristics of transformational change’

These characteristics are by and large ambitions (e.g. ‘wider primary care, provided at scale’ and ‘a modern model of integrated care’).  They represent a direction of travel, but they do not of themselves constitute a plan.  In NHS England’s words they are the ‘characteristics’ of a plan. 

Of course NHS England does not claim to have a plan.  It is for local communities to use the guidance to create robust plans. ‘Plans must be owned locally and driven by local needs. Unlike previous years, this document is not prescriptive in how CCGs achieve this ambition.’ (p25).  So we are free to make our own plans locally.

But before we get too excited there are a few caveats.  There are 21 ‘fundamental elements’ that NHS England will use to assess the scale of ambition and plans for implementation, with 47 ‘key features’ to be demonstrated in plans.  These features include:

  • how you will enable primary care to operate at greater scale to improve access and continuity of care and to enable your urgent and emergency care network to function effectively’
  • ‘how you have considered your model of elective care for your local providers to achieve a 20% productivity improvement within 5 years, so that existing activity levels can be delivered with better outcomes and 20% less resource’
  • ‘how your strategic plans address whether your providers are seeing and treating a sufficiently high enough volume of patients to meet specified clinical standards, in line with the need to concentrate specialised services in 15-30 centres of excellence, linked to Academic Health Science Networks’

 The NHS has been trying to make these changes, or ones very similar to them, happen for a number of years.  But rather than tell you how to do it, NHS England is simply stating what must be done.  It is the freedom of how to get there that is the preserve of the CCGs.

But whereas previously funding has been available to smooth the delivery of such grand changes, the fiscal environment now offers no such support.  The NHS must save £30bn by 2021, and CCGs must operate within the financial rules handed to them.  These include a 4% non-recurrent requirement for next year (0.5% contingency, 1% surplus, 2.5% non-recurrent expenditure), rising to just over 6% with the money to be found for the Better Care Fund in 2015/16, with a 10% reduction in running costs in 2015/16 thrown in for good measure.

This financial pressure will hit providers, those that CCGs will be asking to support the delivery of these changes, hard.  Most providers already have very gloomy financial forecasts for next year, and I don’t think this guidance will have helped.

You may be thinking that this is beginning to sound like an impossible task, but help, it turns out, is at hand.  The ‘Any Town health system model’ is to be published in January.  This will show ‘how a typical CCG could achieve financial balance over the strategic period covered’.  Before you become too cynical about this please note that, ‘A number of ‘High Impact Interventions’ have been fully impact assessed and included in the report. Twelve ‘Early Adopter Interventions’ are also included; these have not been impact assessed to the same specification as the ‘High Impact Interventions’, but are innovative, cutting edge ideas which may be promising.’  Help, it seems, is at hand.

The big challenge ahead for CCGs could be working out how to make all of the pieces of the jigsaw laid out by NHS England in this guidance into a coherent local plan.  Or it could be finalising an approach that they believe will have the greatest chance of success.  In the little over 6 weeks that remain until the first submission, the question for CCGs is whether to focus on identifying how they will meet all 47 key features of the fundamental elements of the plan, or whether they should focus on getting local sign up and buy in to their approach to meeting the challenge ahead?  In the absence of a national plan, is stakeholder buy in more important than meeting all the requirements of the guidance? 

So in summary there is no overall plan.  The guidance is designed to help local plans be developed.  Whether it is ultimately a help or a hindrance remains to be seen.  Happy New Year!

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Aug
04

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 http://ccginformation.com/why-renaming-the-nhscb-as-nhs-england-is-bad-news-for-ccgs/

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.

Apr
27

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

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

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

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

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

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

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

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

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

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Mar
24

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

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

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

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

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

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

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

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

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

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Dec
24

The NHS Commissioning Board (NHSCB) has launched Christmas with the publication of the Operating Framework last week, which it now confusingly calls ‘Everyone Counts’.  For all the language used by the NHSCB, this was always going to be the real test of how different things are really going to be in the new landscape of the NHS next year.

It starts reasonably well, and on the surface of it the shift to a much stronger focus on outcomes is a really positive step.  However as ever, there is a sting in the tail, which sits in 3.4 of the document,

The NHS Standard Contract is a key enabler for commissioners to secure improvement in the quality of services for patients.  It supports the approach set out in this guidance and as such will be the basis on which commissioners should commission NHS funded services from providers.  Commissioners must enforce the standard terms, including the financial consequences for under-performance or failure to provide data on which to assess performance.  We will be rigorous in supporting CCGs and our direct commissioners to ensure the contract terms are implemented.

Littered throughout the document are also references to specific situations in which the NHSCB will expect CCGs to implement financial penalties, including completeness and quality of data, individual 52 week breaches, and ambulance handover delays over 30 minutes (with a further fine for delays over an hour).

This is not something that is going to start on the 1st April.  Right now many CCGs are being asked to report directly and in detail to the NHSCB as to how contract penalties are being applied where providers are failing performance target.  It would seem that the NHSCB strategy for maintaining ‘grip’ in the new world is ensuring that CCGs are implementing contract penalties.

I know there are mixed views on this.  There is a camp, even within CCGs, that support this approach wholeheartedly.  The contract is viewed as the key tool by which commissioning is delivered, and strong contracting is seen as the enabler by which providers will understand consequences and therefore improve performance. 

For me this does not really stack up.  Clinical commissioning at its core is about clinicians working together to develop services that best meet the needs of patients.  It is built upon trust and honesty and strong working relationships.  It is very difficult for a CCG to on one day have a conversation with its local hospital about working together to transform the urgent care system, and the next day to issue a fine for failure to achieve the 4 hour target.

Do fines really incentivise providers?  Is it really helpful when a hospital has been under severe pressure over a sustained period of time, and front line staff are at breaking point, for the commissioner to issue a financial penalty – one that most likely will lead to more cuts, lower staffing, lower morale, and most likely even worse performance?  As commissioners in our heart of hearts do we think the real issue is that hospitals are not taking performance seriously, and that it is simply a question of insufficient effort, which needs to be galvanised through punitive action?

I do think that there is a role for contract penalties.  There are times when for whatever reason providers take their eye off the ball and do not meet the standards that we expect for our patients.  What CCGs need to do is set their own strategy for use of contracts and contract penalties.  We need to be explicit about what we will fine for and, more importantly, how we will use any income gained from fines.  There is a huge difference between using it to offset an in-year financial problem and using it to reinvest in resolving the identified issues. 

CCGs need to share this strategy with their providers up front, in the explicit context of the Everyone Counts document, and then stick to it.  Page one needs to restate that it is clinical relationships that will drive long term success, not contracts.  If as CCGs we do not do this we will be on the back foot with the NHSCB from the start, and will be storing up trouble and impossible relationships for the future.

Enjoy your Christmas.  Hopefully you will have time to amidst agreeing how the winter money will be spent, producing the first draft of next year’s plan, and responding to all of the Local Area Team’s urgent requests for information!

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Dec
02

There is some noise being made nationally about the financial ‘expectations’ being set for Clinical Commissioning Groups (CCGs) by the NHS Commissioning Board.  These will be published in the financial and planning framework due out later this month.

The basic plan appears to be that CCGs will need to set aside 2% to spend non-recurrently, which is not to be spent on routine services.  This has been the case for the last few years for PCTs, and is unlikely to come as any great surprise to CCG Chief Financial Officers (CFOs).

I understand that for some any restriction on CCGs is symbolic of a continuation of the old regime and of the lack of freedom that CCGs will be given.  However, the size of the financial challenge facing CCGs and indeed the health service as a whole means that system transformation is critical.  For CCGs to rise to this challenge it will require significant investment.

What CCGs can and must do is ensure that they use the 2% for real system transformation.  In the past this funding has been used too often to bail out overspending acute contracts.  CFOs are cautious by nature, and will want to ensure this pot is available at least six months into the year until they have a clearer picture of the likely outturn position.  CCGs must resist this temptation, have clear and strong plans for system transformation, and invest in them.  If they do not they are taking short term security at the cost of long term financial pain.

The rules that the NHS Commissioning Board put around this are likely, if anything, to be helpful.  They can set the expectation for providers and the system as a whole that this funding cannot be part of contract negotiations.  In some places providers treat the 2% funding as if they have a right to their ‘fair share’ of it.  What the guidance can do is provide more clarity that it is for CCGs to use to drive system transformation however they wish.

The remaining money that CCGs are being (potentially) asked to set aside is in two parts.  The first is the money based on the ‘control total’ that historic PCTs had to achieve.  So while this may work out as 1% for CCGs across the country (as reported by the Health Services Journal 22/11/12 p5), as long as this is returned from the surpluses that PCTs achieved I cannot imagine this will cause an issue for the vast majority of CCGs.

The second part is an expectation that CCGs will create an internal contingency to ensure they achieve balance.  I am yet to meet a CCG CFO who was not planning to do this.  The issue could be if the NHS Commissioning Board dictates an amount, but if it is a minimum of 0.5% as reported it is unlikely that many would be planning for less than this.  If anything, it will provide support for those CFOs who’s GPs are insisting that no contingency is required!

It is likely that there will be issues that need resolving between CCGs and the NHS Commissioning Board.  CCGs must pick their battles with the Commissioning Board carefully, and make sure that when the time comes they choose the right ones.  The financial planning guidance, however, is not one of these.  CCGs must demonstrate the ability to keep control of the financial position, while at the same time using the power of clinical commissioning to transform the system.  A prudent and effective use of contingency funds is key to this, and the guidance is more likely to help than to hinder.

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Sep
14

Every week a new layer of complexity seems to be added to the authorisation process.  This week we discover “temporary” restrictions are to be placed on Clinical Commissioning Groups (CCGs).  In previous weeks we have been told there are to be seven types of “conditions” placed on CCGs.  These conditions will be administered by a “conditions panel”.  However, the conditions panel will not actually make decisions about conditions.  It will only recommend them.  The final decisions will be made by a “CCG Authorisation sub-committee” of the NHS Commissioning Board (NHSCB).  And I haven’t mentioned the moderation panel…

What are we to make of this?  The process is outlined in a paper by Barbara Hakin for the NHSCB, which can be found here http://www.commissioningboard.nhs.uk/files/2012/09/board-4-ccg-auth-gov.pdf .  Why create such a process?  The paper states the intention is to,

“Design an approach to moderation, conditions and decisions that is consistent, proportionate, transparent, and legally compliant, supporting the delivery of an efficient and consistent decision-making process. The process design will be accompanied by template documents and conditions to further support efficiency and consistency. This rigorous approach will also protect both the NHS Commissioning Board (NHS CB) and CCGs by ensuring that the risks of CCGs taking on responsibilities before they are ready to do so are minimised, whilst maximising the opportunities for full authorisation.”

Really.  Either someone has been spending too much money with their lawyers, or else the need for control is starting to be expressed by the NHSCB in the way the authorisation process is developing. 

The authorisation process is important not so much because of the outcome, but because of the nature of the relationship it will set between the NHSCB and each CCG.  The Health Service Journal reports,

One reason for the conditions will be that groups are required to demonstrate strong and “credible” operational and service planning for 2013-14, including how they will achieve financial balance.  Few CCGs are in a position to do so and no framework or guidance is yet in place.”  HSJ, 13 September 2012, p6

This is significant because the authorisation process is now not an assessment of the overall capability of the CCG to create a clear and credible plan, but an assessment of the plan itself.  The implication is that all CCGs will potentially be given a condition that they must produce a plan which has to match NHSCB expectations, regardless of the capability of the leadership team.  Producing a plan based on local requirements rather than on those developed nationally or regionally will not, it seems, be allowed.  The NHSCB will not sign off such a plan, and the CCG’s statutory responsibility to produce the plan will not be conferred until a plan is produced that the NHSCB approves of.

Worse, if the noises about authorisation becoming an ongoing and annual, rather than one-off, process are correct, this could easily become the tool by which the NHSCB exercises control over the freedoms given to CCGs in the legislation (i.e. by only releasing those freedoms when the CCG has acted in accordance with the wishes of the NHSCB).

Authorisation, however, should be about enabling freedom, not taking control. 

 “Freedom is actually a bigger game than power.  Power is about what you can control.  Freedom is about what you can unleash.” Harriet Rubin

The system cannot continue to operate through tight central control.  CCGs rightly need to earn their freedom.  The authorisation process should test each CCG’s ability to wield its freedom effectively.  It should not seek to establish control on how CCGs operate. 

Each layer of complexity that is added to the process is another layer of control being developed by the NHSCB.  If CCGs do not find a vocal national advocate soon, and a way of collectively standing up to the NHSCB, they will be sunk before they have even set sail.

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Aug
18

There was a significant development this week.  David Nicholson wrote a letter to Chief Executives saying that management responsibility was shifting from PCTs and SHAs to the NHS Commissioning Board (NHSCB) from the 1st October.  The letter said,

“For the NHS Commissioning Board, people appointed to the future regional and local leadership roles in the NHS Commissioning Board should take on management responsibility for the teams managing both 2012/13 operational delivery and planning for 2013/14.” (https://www.wp.dh.gov.uk/publications/files/2012/08/DN-letter-to-system-secure-transition.pdf )

This really is a momentous shift, as PCT Clusters and SHAs are stripped of their power.  But what does this mean for Clinical Commissioning Groups (CCGs)?  Well, it then goes on to say,

“The arrangements I have outlined above will not impact on Clinical Commissioning Groups (CCGs) or Local Authorities as they prepare for their key roles in the new health and social care system.”

Really.  That feels a bit like saying that the manager of a football club will be changed for 6 months of the season, but it will not have any impact on the players.  I am not sure whom David Nicholson thinks is actually doing operational delivery this year, but for the most part it is CCGs and not PCT Clusters.  Shift in ‘management responsibility’ therefore means ‘management responsibility of in year CCG performance’.  

What therefore is the impact likely to be for CCGs, and how should CCGs respond?  Here are 4 key actions CCGs should be taking now:

1. Reset expectations for taking control from 1st April 2013 to 1st October 2012.  There is a window of opportunity that has been created for CCGs to take responsibility early.  There will inevitably be a vacuum as the PCT Cluster executive teams lose control to the NHSCB.  CCGs need to behave from the 1st October as the local system leaders.  Failure to do this now will result in the NHSCB taking over, and this will then prove extremely difficult to change post April.

2. Get hold of the PCT Cluster reserves.  However strong the relationship between the CCGs and the PCT Cluster I guarantee the PCT Cluster will be holding financial reserves.  PCT Cluster Chief Executives and Directors of Finance do not want their legacy year to be one of falling into financial deficit.  The opportunity for them in the delegation of budgets to CCGs was to performance manage QIPP delivery and influence GP behaviour in a way they had never previously been able to, while always keeping a slush fund to ensure end of year balance. 

The problem is these Chief Executives and Directors of Finance are losing control 6 months early, and will be off to pastures new.  It is critical that CCGs have the honest conversation and ensure that they get their hands on these funds, because otherwise they will go to the NHS Commissioning Board.  And if the CCG down the road is in more trouble than you, that is where those funds will end up.

3. Build a relationship with the NHS Commissioning Board.  The change to the new style of leadership will be the greatest tangible impact upon CCGs.  For some this may mean moving to a more directive style, but others may find the style moving in the opposite direction.  Either way the time is now for CCGs to develop an adult-adult relationship with the NHSCB, and move away from the parent-child relationship many CCGs have had with their PCT Clusters.

CCGs must plan their interaction with the NHSCB.  They must always be well prepared, always be knowledgeable about current performance, and always be on top of the finances.  Conversations need to be shaped about what the NHSCB can do for the CCG and not vice versa.  The key is not giving the NHSCB any opportunity to take control of your area.

4. Collaborate with other CCGs.  The NHSCB has an opportunity with this early shift to establish control over CCGs.  Whilst on the one hand this shift gives more freedom than has existed previously to CCGs, on the other it potentially could restrict the amount of freedom CCGs have in future.  To counter this CCGs need to work together.  They need to share information and intelligence on interaction with the NHSCB.  They must create a single coherent voice to enable them to push back effectively when the NHSCB oversteps the mark (which it will!).

The time for CCGs has come 6 months early.  This is an opportunity and at the same time a significant risk.  The government has gone to great lengths to put CCGs in charge.  But at the end of the day the legislation can only ever take us as far as the water.  It is up to us to drink.

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Jan
28

The NHS CB has published on a public website papers for its board meeting on the 2nd February.  You can find them here:

http://www.commissioningboard.nhs.uk/2012/01/26/board-meeting-020212/

The papers cover a number of areas relevant for CCGs, in particular: Organisational Design of the NHSCB; Governance for CCGs; Authorisation of CCGs; and Commissioning Support.  The only wholly new paper is the one on the Organisational Design of the NHSCB.  The CCG Governance paper was produced in draft last year and while it has been updated contains only minor changes.  The CCG Authorisation paper was produced in September last year, and the Commissioning Support paper has been available in draft since December last year.  Most of what is ‘new’ appears in the covering papers, and for those who do not have a spare half day to read through everything our advice would be to concentrate your efforts there.

Key messages for CCGs

What CCGs are really looking for out of the Organisational Design paper is what it means in terms of how they are going to be managed.  Some of the answers are starting to emerge.  There will be local offices of the NHS CB that outside of London map more or less to the existing PCT Clusters.  Each will have a local office director, a medical lead responsible for direct commissioning, a head of finance responsible for CCG assurance and a nursing lead.  According to the Health Service Journal (26/01/12 p4) Bill McCarthy, NHS CB Managing Director has, ‘urged PCT Cluster Chief Executives to consider becoming Director of their local board office’.  So now we know that there is a high probability that the current PCT Cluster CEOs will have the main responsibility for performance managing CCGs, and that they will do that through their Head of Finance (?existing Cluster Director of Finance) and a team of about 10 staff dedicated to ‘CCG assurance’.

So what does this mean for CCGs today?  It means maintain positive relationships with your PCT Cluster CEO, Director of Finance and Director, Medical Director and Director of Nursing, because many may not be going anywhere fast.  As we move into ‘shadow running’ next year they will be taking on the NHS CB role of ‘providing development support, and monitoring performance and outcomes’.  Expect them to have a significant role in the authorisation process!

The other take away message is the strong emphasis there is going to be on the Commissioning Outcomes Framework.  PCTs were not set up to drive outcomes in the way that CCGs will be expected to.  CCGs need to be considering how they will establish their infrastructure to ensure they are driving improvements in outcomes.  Quality leads will need to take on a dual responsibility for improving outcomes as well as quality assurance.  CCGs need to be framing the support they will be receiving from public health in terms of the Commissioning Outcomes Framework, and ensuring they are driving the way the Health and Wellbeing strategy is being shaped locally to reflect this.

The most noteworthy fact about the governance document is the gap that exists between the governance requirements of CCGs, and the governance documentation that CCGs are currently putting together.  Many CCGs claim to have a constitution signed by all member practices, but the reality is these will need tearing up and starting all over again.  The failure to produce a model constitution by the NHS CB to date (it was initially promised by the end of December) I suspect will come back to haunt them, because CCGs are in for a shock when they see it, and it will be a significant challenge for these to be ready in time for authorisation.

The new information about authorisation appears in the covering paper.  There will be two phases to authorisation.  The first pre-assessment phase will be run by the existing SHA Cluster.  The previous outline of further authorisation gateways to include governance in January and leadership in March has been changed to the production of ‘development checklists’ covering configuration, governance, leadership, commissioning support, planning and core infrastructure.  This appears to be a moveable feast, so expect regional variation and more changes to come in this area.  The second phase is formal assessment by the NHS CB.  Applications will be in 4 tranches, with the first in July (completing in October) and the last in October (completing in January).  It does not take a genius to work out that if 220 authorisations are to be completed start to finish in 6 months the majority of the process will have to be carried out by the existing PCT Clusters.  A big question for CCGs is whether there is any benefit in going in an early tranche, or whether they would be better learning from those brave (daft) enough to go first.  Expect CCGs to start fighting to be part of tranche 4 rather than tranche 1.

The Commissioning Support documentation is the one released at the end of 2011.  The interesting expectation is that CCGs will have at least shadow SLA arrangements in from April 2012.  A big call for CCGs is do they push for very detailed specifications (which push a ‘work to contract’ mentality and create arguments when work is required by the CCG that has not been specified) or very loose specifications (which create arguments because of differing levels of expectations on the two sides as to what will be provided).  It seems there is very little time for CCGs and commissioning support organisations to work this through and get the balance right.

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