Archive

Archive for the ‘CCGs Together’ Category

Jul
28

I am Ben Gowland.  I am the Chief Executive and Accountable Officer at NHS Nene CCG.  I have run the Clinical Commissioning Groups Information website anonymously for 18 months, but have decided now to ‘come out’!!

When I started this site I thought it would be better to stay anonymous.  I thought it would enable me to say exactly what I wanted, and not be constrained by the impact my views might have on my CCG or on those around me. But, it turns out, I was wrong! 

As the website has grown in popularity I have been encouraged to make it my own.  The feedback has been that it is hard to trust an anonymous site, that it restricts interaction, that it creates a nervousness as to who or what is behind it (e.g. is it a trojan horse for pharma).  If the aim is to provide the greatest possible support to CCGs (which it is), and if the impact will be greatest by being me rather than by being anonymous (which I now believe it will), then coming out is the only possible way forward.

I have discussed the potential impact of the site on my CCG with colleagues.  Their feedback has been that I absolutely must make the site my own.  They looked at the content on the site and could not see any reason why it would impact negatively on the CCG, and on the contrary felt that in the NHS today openness and transparency have become critically important.

As those of you familiar with the site will know, I am passionate about the potential of Clinical Commissioning Groups.  I firmly believe that decision making about the use of NHS funds needs to sit with those directly involved in the delivery of front line care, and that those best placed to be leading this are GPs. 

In the past I have worked in organisations where managers insisted on leading organisational decision making, and on relegating clinicians to a support role at best.  Since then I have set up organisations (first Nene Commissioning as a practice based commissioning organisation, and now NHS Nene as a CCG) where clinicians are empowered and supported to use commissioning to make a real difference to the lives of their patients.

Clinical Commissioning Groups need all the help that they can get.  This website is my contribution to supporting CCGs as a collective to fulfil their potential.  In the transition from PCTs we have not had a really strong advocate, and no one really rooting for us.  Latterly NHS Clinical Commissioners has taken on this role, which we have desperately needed, and I think alongside them we need as many of us as possible giving our views and making our voices heard.

Thanks to those of you who have supported me and encouraged me up until now.  I hope that all of you will continue to work with me, and that we can work together to support and develop CCGs so that they can fulfil their incredible potential!

Jul
14

Now that the first 100 days of CCGs has passed, it is time for the first review of CCGs.  A number of articles have been produced by CCG leaders, which unsurprisingly are optimistic.

Writing in the Guardian (here) Dr Steve Kell concludes, ‘After 100 days I’m optimistic clinical commissioning is delivering’.  Michael Dixon writing in Inside Commissioning says the positive outweighs the negatives.  He states, ‘Already, it is clear that the new clinical leaders of CCGs are strong, committed and clever. They will not be deterred by the skewed rules, vested interests and paralytic inertia of the system that they have inherited.’  You can find the full article here

I, however, am not so sure.  The reality is that in the past 100 days, Andy Burnham has announced that Labour policy will be to put CCGs in a support role and give commissioning to the Health and Wellbeing Boards.  Jeremy Hunt has transferred £3.8bn to councils from CCGs.  David Nicholson has announced a review of NHS strategy to test the purchaser-provider split, and hospital chief executives have joined in saying they can’t see the value in the purchaser-provider split.

Jeremy Hunt has also made ‘taking on’ the GPs and the GP contract a priority, without any reference to the GPs’ role as commissioners.  The RCGP has produced a vision for general practice without any thought to the impact of commissioning on the profession. 

Clinical commissioning, it would seem, is not as visible as it could be.

We said on this site that the idea of the first 100 days as a honeymoon period are long gone.  Instead it is the basis upon which judgements are made as to the leadership potential for the future (see the article in full http://ccginformation.com/the-first-100-days/). 

It is undoubtedly true that CCGs have entered a turbulent political context.  But priority one has to be establishing a strong voice.  As it stands no one knows who we are.  Most members of the public could not tell you what a CCG is.

To have a strong, credible voice CCGs need to do a number of things.  First we need to develop some easily recognisable clinical leaders to become the front for CCGs.  Second we need to point to some clear deliverables.  Third we need to be clear on our key priorities for the future.  And lastly we need to set out and establish our long term vision.

Steve Kell is becoming a good lead voice for CCGs.  Collectively we need to get behind him and support him in this role.  If we do not develop a strong voice, and do not do it quickly, as CCGs we will not even get a chance to start to fulfil our potential.

Mar
16

The history of Clinical Commissioning Groups (CCGs), short as it is, has conspired to set CCGs up in competition with each other.  At a time when many are already predicting the demise of CCGs, it is critical that CCGs work together to be successful.

So how has this situation come about?  The primary reason is the authorisation process.  This created a competition between CCGs (‘What wave were you in?’, ‘How many conditions do you have?’ etc etc), that is neither helpful now, nor conducive to future success.

This competitiveness stems from the origins of CCGs as self-selected groupings of GP practices.  These groupings often set up around historic alliances and rivalries.  Once practices made a choice as to where their allegiances should lie, they naturally wanted to validate this decision making by demonstrating that ‘their’ CCG was better than the CCG they had chosen not to join.  This has meant that the biggest barriers to joint working exist between neighbouring CCGs with whom the strongest alliances are most important.

Some CCGs have already had to deal with some of these turf wars as different groups have had to come together to form a larger whole.  Making this work internally has taken such effort that building relationships with other CCGs has understandably taken a back seat.

The limited management allowance, and the fact that many GPs are carrying out the commissioning role in 1, 2 0r 3 days per week, mean that the capacity for collaborative working between CCGs has not existed, even when the desire to do so does.  Completing the collaborative agreement template that exists for CCGs remains on the to do list of most CCGs, rather than the tasks completed list.

The time has now come to draw a line under the past and put an end to any competition.  It is incomprehensible that at this stage any one CCG has all the answers.  It is critical that CCGs learn from each other, because ultimately we will succeed or fail as a collective.

CCGs are totally new organisations.  There are sets of issues that CCGs are dealing with that predecessor organisations such as PCTs never had to, such as creating effective governance as a membership organisation of GP practices, developing meaningful and sustainable practice engagement, managing the NHS Commissioning Board, and making commissioning support effective.

So what can we do to learn from each other?  How can we recognise the constraints that we all operate under, and yet create the capacity to learn from and support each other?

The starting point is for CCGs, individually and collectively, to commit to doing this.  It is critical we are active in this, and do not leave it to others (in particular the NHS Commissioning Board) to arrange on our behalf.  We must decide for ourselves what good is, and find ways of sharing and learning that are effective for us.

This website is one opportunity for sharing between CCGs.  One of the most common requests we receive is for case studies on how individual CCGs have successfully met some of the challenges they face.  So here are three things that you personally can do to help the development of collaboration between CCGs:

  1. Request information and advice from other CCGs.  Use this site to pose questions that you want the answers to.
  2. If you or your CCG has a case study of success in any of the categories in the sidebar of this site, send them to us and we will gladly publish them to make them accessible to others.  We have had specific requests for examples of how CCGs have created strong practice engagement, and of where CCGs have developed effective primary care strategies, so if you have examples particularly in either of these areas we would be more than happy to publish them.
  3. Finally, tell other people who work in CCGs about this site.  The more we share and learn together, the stronger we will be!

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Oct
26

You may or may not have heard of Epanutin.  It is a drug that was previously marketed and distributed by Pfizer and, since the 24 September, is being marketed and distributed by Flynn Pharma.  There is no difference in the way the capsules are being manufactured.  The only changes are to the name, and to the price.  The increase in price is a jaw dropping 24 fold increase.  The cost pressure to the NHS is likely to be £50M per again.  It provides no additional health benefits for patients.

So how should CCGs respond?  The usual work arounds are not available: there are no cheap generic alternatives, and no parallel imports.   Do we just take it lying down, and accept that it is the world we are operating in, and that these things are just going to happen?

I would suggest we do not just accept this.  It could well be that the pharma companies in these economically distressed times, seeing the general disarray caused by the reforms, are simply chancing their arm to see what they can get away with.  If this is the case it is very important that Clinical Commissioning Groups (CCGs) are seen to be strong collectively as well as individually, and that they are not providing an environment that allows the NHS to be taken advantage of.

There has been some press interest in this, see for example:

http://www.telegraph.co.uk/health/healthnews/9604683/Pharma-firm-hikes-cost-of-epilepsy-drug-24-times.html#

The (minimal) public reaction to this interesting: an automatic assumption of blame to the NHS for allowing it to happen rather than to the pharma companies for concocting it.  The pharma companies simply hold a line that the new price is a more accurate representation of the true costs.  Pfizer still manufacture the product, but in this arrangement can allow the much smaller Flynn Pharma to take the reputational hit for the price hike.CCGs do not have now, and will not have in the future, £50M per year to fund price hikes like this.

I know a number of CCGs are now writing to their MPs, their local papers and whoever they know who has influence.  If all of us do what we can and can somehow get this changed, we will not only be doing a service for  the NHS as a whole, we will be sending a clear message to those watching about the consequences of these types of decisions, and maybe prevent some of them happening in future.

Aug
25

As the new landscape unfolds a clear gap is emerging.  Large scale procurements, strategic planning, indeed any activity that requires an at scale approach, are at risk of falling into no mans land.  If the NHS is to be commissioner-led, then Clinical Commissioning Groups (CCGs) cannot allow this to happen.

Clinical Commissioning Groups need to find ways of working together.  This is not the same as groups of practices working together within a multiple CCG federated structure.  This is about different CCGs developing effective mechanisms of joint decision making, and of creating a clear commissioner voice across an area larger than any individual CCG.

When might this be needed?  The obvious examples are at-scale procurements such as pathology, and service reconfigurations to shape the acute provider environment.  The financial climate means that these types of initiative are going to be more important and more necessary in the future than they have been in the past, and yet there is no obvious mechanism of making them happen.

To be fair, the NHS Commissioning Board (NHSCB) has recognised this.  They have published guidance on collaborative commissioning between CCGs.  You can find it here http://www.commissioningboard.nhs.uk/files/2012/03/collab-commiss-frame.pdf.

As ever, this guidance raises more questions than it answers, and basically sends the message that CCGs need to work it out for themselves.  It does however ensure that the right questions are being asked.  There are two important principles to bear in mind.  The first is espoused in Annex 1 of the document,

“Where two or more CCGs engage in collaborative commissioning arrangements, the individual CCGs will retain liability for the exercise of their respective statutory functions for their areas. This cannot be delegated or shared, and the arrangements must recognise this. Two or more CCGs could have a joint working committee as the hub of their collaborative arrangements, but such a committee could not make decisions directly of its own authority which would bind the CCGs, as legislation does not provide for this.” p22

This creates a real problem for CCGs, as it means that any joint arrangement that is made cannot be binding on the CCGs involved.  All CCGs retain sovereign responsibility for their population.  If a CCG is going to delegate decision making ability to an individual on a joint committee it needs to consult its member practices in order to amend its constitution to enable this to happen.

So the second principle is how CCGs will resolve any differences of opinion, as any arrangements that are developed necessarily preserve the ‘walk-away’ option for any CCG.  The last thing that CCGs need at this point in their collective development is the collapse of any collaborative arrangements, sending a clear signal to providers that the shift to CCGs is strengthening their hand.

It requires CCGs who are forming collaborative arrangements to work through how they will resolve differences of opinion before they occur.  Ultimately CCGs in a group cannot stop one of their number from walking away.  But what they can do is to create a mechanism for ensuring that any differences are given the best possible chance of being resolved, through the development of escalation procedures that may ultimately include the introduction of independent arbitrators.

The pressures of authorisation, coupled with many CCGs operating without a full complement of resource, means that the creation of these arrangements has to date been relatively few and far between.  The NHSCB have promised a model agreement for CCGs in the autumn.  As CCGs develop these agreements they would do well to share them with each other.

Leaders of CCGs should be prioritising building relationships with the leaders of other CCGs.  These relationships are going to be crucial to long term success.  CCGs are not and should not be competing with each other.  They are on the same side and need to work hard at collaborating to ensure that CCGs collectively are successful.

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Apr
08

The most common way people give up their power is by thinking they don’t have any’ (Alice Walker).

Following the passage of the Health and Social Care Bill, it should be a time for CCGs to be harnessing their power and creating the commissioning landscape around them.  It seems however, that at just this very point the power of CCGs is being increasingly eroded by the NHS Commissioning Board.  This is happening in a number of ways:

1.  CCG senior leaders are to be appointed according to an NHS Commissioning Board designed process.  Why is this ok? Why are senior leaders within CCGs accepting this process and meekly complying with it?  Chief Financial Officers have to go through two separate assessments because different parts of the NHS Commissioning Board were not speaking to each other and set up two different processes!  Accountable Officers, many of whom have already given up their share of practice partnerships, are being told that they cannot be appointed until they have 1) been through an assessment centre with no evidence base using quasi-scientific method to determine whether they are suitable or not; 2) been through (yet another) recruitment process within the CCG; and 3) are approved by the NHS Commissioning Board post-authorisation.  How is this a reasonable or acceptable process?  What it does of course is keep direct appointment power by the NHS Commissioning Board over Accountable Officers deep into next year, which in turn reduces the chances of real opposition to the Commissioning Board being vocalised.

 2.  The NHS Commissioning Board is designing an authorisation process that shapes CCGs in the way that it wants them to be shaped.  The rhetoric around co-design turned out to be simply that – rhetoric.  It is mandatory in the Health and Social Care Act that Clinical Commissioning Groups are statutory bodies that carry out commissioning.  CCGs are unwittingly allowing the NHS Commissioning Board to shape the way this happens through the authorisation process.

3.  The expectation of use of Commissioning Support Services (CSS’s) by CCGs and the geographic development of CSS’s.  I understand that there is value in companies determining their core competence and outsourcing to other companies areas that are not their core competence.  What I do not understand is how CSS’s are being developed on a geographic area basis rather than a core competence basis.  It makes no sense.  A CCG needs to be able to access the best supplier of contracting support for the model to work.  Accessing it from the local CSS simply because it is local makes no more sense than providing it in-house.  In addition all CSS’s will be hosted by the NHS Commissioning Board until 2016 and they will appoint all senior leaders of CSS’s.

It is a myth, perpetuated by the NHS Commissioning Board itself, that CCGs are run by clueless GPs and their receptionists, and that the NHS Commissioning Board is preventing the NHS from collapse by intervening in the way CCGs are run.  This is not the case.  CCGs can and are approaching commissioning in much more powerful and effective ways already than were ever achieved by PCTs.  The biggest current risk they have is that they give up the right to choose the way they do business, and assume somehow that the NHS Commissioning Board knows better than they do.  CCGs must find a collective voice, which acts as a powerful antidote to the NHS Commissioning Board, and use the power that has now been given to them by law.  If we do not act soon, it will be too late.

Frank Herbert, author of Dune, sums this up well, ‘If you think of yourselves as helpless and ineffectual, it is certain that you will create a despotic government to be your master.  The wise despot, therefore, maintains among his subjects a popular sense that they are helpless and ineffectual’.

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Feb
18

Any organisation in the NHS needs an organisation that is prepared to fight their corner nationally.  Doctors have royal colleges and the BMA, NHS managers have the NHS Confederation, and while all are not equally effective, at least they have a voice.  In the midst of the turbulence surrounding the passage and implementation of the Health Bill, it is critical that someone represents CCGs.

But who have we got?  Clare Gerada and the RCGP oppose the bill, and are doing very little to help CCGs with the challenges they face today.  Laurence Buckman and the GPC are committed (understandably) to protecting GP practices, and so regularly come out with guidance for practices similar to the one earlier this year urging practices not to sign any CCG governance agreements.  The NHS Alliance and NAPC coalition should be the organisation providing the voice.  Unfortunately the replacement of the solid Johnny Marshall with the more outspoken Charles Alessi, working alongside the maverick Michael Dixon, means there is not a strong credible clinical leader at the head of the organisation.  They have let CCGs down in their recent 111 paper by not rallying CCGs to resist the proposals collectively until the funding for NHS Direct follows.   The NHS Confederation has done nothing to support CCGs so far, and has its heart with acute hospitals and their managers.

This lack of a national voice comes at the worst possible time.  We are now right at the heart of the move of responsibilities to CCGs, at a time when most are still fledgling, vulnerable organisations.  Examples of where a national voice is required include:

  • Ensuring the recruitment/appointment process of Accountable Officers/Chairs/Chief Finance Officers is not set up in a way that simply moves PCT Cluster executives into these roles, regardless of the wishes of the membership
  • Ensuring the CCG management allowance is protected.  We are still to see clarity on how it will be calculated (e.g. weighted populations), what it will cover (this week CCG buildings have been added to what it needs to pay for).  Many CCGs still have not been given the information as to what their current costs are, and are being prevented from making explicit decisions as to how to use it.
  • Input into the authorisation process, specifically who is doing it and what the consequences of success or otherwise are.  Failure to influence this effectively could result in most CCGs operating within a straitjacket from day one.
  • Establishing the CCG budgets, and influencing what is transferred from historic PCT budgets to CCGs, public health, the NHS Commissioning Board and others.  There is a real risk that CCGs will get what is left rather that what they need.  There is no clarity today at to where historic reserves sit next year, and many PCT Clusters will sit on these reserves, accuse the CCGs of failing and use the reserves to balance the position.

There are many other live current examples.  We need a national voice urgently, and it is not obvious where it is going to come from.  Should CCGs be acting together to set up something new? Should we be lobbying the NHS Alliance/NAPC Coalition to change their leadership team so that they can be effective?  I would love to hear your view – email me at mail@ccginformation.com .

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