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Archive for the ‘The Basics of CCGs’ Category

Sep
02

I recently received a letter from a local man with Parkinson’s Disease.  Hearing from patients, and gaining just a small insight into their lives, is one of the privileges that working in a CCG brings.  I want to share with you the story that he shared with me, and that he is happy that I share with you, directly, and in his words.

‘Whenever I have been asked, ‘How do you feel today?’ there is a simple 3 word answer: ‘Abandoned’, because we have been.  ‘Angry’, not at the condition (that is pointless). I am angry at the way we are treated.  How much use in reality is one 15 minute consultation with your neurologist every 12 months?

The last word is ‘frightened’, not just for me but for my wife, my children and grandchildren. I am in the middle of a ‘bad patch’.  It’s not nice when Parkinson’s Disease rears up and bites. This morning my wife wasn’t speaking to me and to make matters worse I was having a really bad “off” start to the morning. We still were not speaking at lunch time. Paranoid as men are in these circumstances, I pushed to find out what I had done wrong – it flared up for the first time in 4 years of marriage that we had really gone off at each other. 

I got in the car and drove off for 1/2 an hour.  Walking was out.  If I could have managed 100m today it would have been a miracle. When I got back we sat at the dining table, held hands, and I asked, ‘come on, what’s up?’.  ‘I’m scared. I’m scared for you and I’m scared for me’ was her answer, and the only thing I could say was, ‘That makes two of us then’.

There’s nothing I can add to this.  It brings home the responsibility we have to the communities and to the individuals that we serve.  Sometimes commissioning can get reduced to QIPP plans and financial reports.  But really the point is how are we, how am I, making a difference to the lives of the individuals who need us.

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Feb
02

Last week I met up with a friend whom I hadn’t seen for a long time.  He asked me what I did for a living, and I replied that I worked for a CCG.  He asked me what a CCG was.  Good question.  I said it stood for Clinical Commissioning Group.  He was none the wiser.

It is an odd thing that ever since the purchaser provider split was introduced the idea of a ‘purchaser’ of healthcare has not really been understood by the public, or pervaded into the public consciousness.  PCTs were never really able to establish any form of identity, other than maybe as the organisation that wouldn’t fund treatments for specific heartbreaking cases.

The mistake I think is starting with a description of what a CCG is, or worse, a description of some of the legalities that sit around it.  It is a fast track to someone glazing over when you start to talk about being a statutory body that is being authorised by the NHS Commissioning Board with an individual constitution agreed by member practices!

The starting point is to understand why CCGs exist.  Ok, so why do CCGs exist?  Most CCGs have a vision/mission statement that goes along the lines of, ’to improve health outcomes and the quality of health care provision for the local population’.  The job of a CCG is to keep you healthy and make sure you get good care if you get sick.

Whilst this is a noble goal, it remains slightly nebulous.  Isn’t that the role of the local hospital?  Hospitals are easy concepts to understand.  They are where you go when you get sick and it is too complicated for your GP (or if you can’t get through to your GP!).  So what is the difference between a CCG and a hospital?

On the one hand they feel so different that it seems like a ridiculous question, but on the other it is true that hospitals and CCGs are both trying to improve health outcomes and the quality of care that is provided to those who need it.  So what really is different?

At this point there is a route we can choose to go down.  The difference is essentially that CCGs decide how NHS money is spent to keep you healthy and make sure you get good care if you need it, while the hospital’s job is to turn the money they receive from the CCG into great quality care.

Whilst this is true at its core, it is not attractive as a primary descriptor of CCGs.  It turns the CCG into an organisation that is then a middle layer of bureaucracy.  The government give the money to the CCG, who in turn give the money to the hospital.  What is the point?  Why doesn’t the government just give the money directly to the hospital, and save the millions of pounds it spends on CCGs?

We need to clearly articulate the value-add to that middle step that CCGs bring.  This is the key.  CCGs are made up GPs and GP practices.  They are membership organisations, with GP practices as their members.  So for a start this means that it is clinicians who are deciding how the NHS money is spent.  Not only is it clinicians, it is GPs.  90% of all healthcare contacts in the NHS are with GPs.  No-one understands the healthcare needs of a population served by a GP practice better than the GPs working in that practice.

Second, GPs in CCGs don’t simply decide how NHS money should be spent.  They work with doctors and nurses and other clinicians to design and implement new ways of working that will improve outcomes and the quality of care that is received.  So for example most GPs that I know are using the CCG to change the provision of services for people who want to die at home.  GPs know that most if their patients want to die at home with those closest to them around them, in an environment they feel safe and secure in.  GPs in CCGs are working with clinicians from hospices, hospitals, district nursing services and the voluntary sector to put the services in place to ensure that this is possible.

So what is our elevator pitch?  I think it goes along these lines.  CCG’s (Clinical Commissioning Groups) are groups of GP practices that decide how the NHS money is used in a way that means their local population is as healthy as possible and receives high quality care when they need it.  They use their understanding of their own patients, and their relationships with doctors, nurses and other healthcare professionals, to buy (‘commission’) the services that best meet their patients’ needs.  Because clinicians rather than managers are in charge, the NHS is safe in their hands.

I tried this with my friend.  He could understand what a CCG was.  His problem was that he had never heard of a CCG.  As a group it is critical that CCGs are not anonymous in the way that PCTs were.  We must use the trusted voice of the GP so that CCGs find their way into the public consciousness.  And we must collectively find a way of describing ourselves that is both easy to understand and that is consistent.

If you have a better alternative we would love to hear it – leave a comment, or send it to us at mail@ccginformation.com.

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Nov
03

What is the goal of health care? This is one of those questions that looks easy, but behind it lies the heart of the transformation that CCGs are trying to achieve.

So what do you think? The most common answer is to provide a service that is there when I need it, to alleviate my suffering and to make me better. If I get sick, a good health care system will return me to health as quickly and effectively as possible.

Wrong.  The goal of healthcare should be to stop me getting sick in the first place.  It should help me understand myself and the impact of the choices I make upon my health. It should help me manage any long term conditions I have as effectively as possible so that I don’t need regular reactive health care.  It should partner me through my life so that I stay healthy.

This paradigm shift in the way we think about health care is needed not just by the receivers of health care, but by the providers of health care.  It leads to partnerships between providers and individual patients, based around their specific needs.  It provides a service that is proactive in managing the needs of patients, and sees the provision of an emergency service as a failure not a success.  We should not be surprised when our patients get sick. Rather we should know in advance that this is going to happen.

In New York Steve Berger was put in charge of a committee to tackle the issue of skyrocketing costs in healthcare.  This committee came to the understanding that this understanding of the goal of healthcare lay at the heart of the change that is required. They understood that there is a massive oversupply of ‘failure capacity’, and that this needs to be reduced.  Alongside this funding systems need to be changed from fee for service payments (i.e. activity based funding like payment by results) towards capitation based funding for the delivery of quality outcomes for specific populations.  Providers should be incentivised for preventing the need for admission rather than for the admission itself.

A health care service designed to prevent the need for health care looks radically different to the one we have today in the NHS.  Its focus is on registered populations receiving the inputs they need at the time they need them (not at the time they choose to present).  It means provider networks designed around population health need. It is affordable in today’s economic climate because the investment required in maintaining health is less than the saving achieved by having less ill health to treat. If we are serious about improving quality and reducing cost this is our only choice.

But what can CCGs do? A this stage we can only do three things.  First we can make it explicit that this is where we are going, in all our communication.  We need to drive the cultural change needed in our communities in their expectations of health care.  We can be clear 100% of the time that this change is needed.  Second we need to be honest that we will make mistakes as we set out on the journey.  We don’t know exactly how to achieve it, and we will need to test out different models. Some will work and some will not.  Third we need to set the expectation that the change we are describing will not be achieved overnight.  It will take us a decade, maybe longer, to figure out the answers.

But if we are clear on our goal, and keep our eyes fixed on it, it is a transformation that CCGs are uniquely placed to deliver.  Steve Berger would love the chance to try and implement his changes in the relatively simple environment of the NHS.  He would start dancing if he had a primary care system set up and capable to drive the change! He may or may not be successful in getting this to work in New York, and may even be stopped dead in his tracks by the election result on Tuesday, but there is nothing to stop CCGs making this happen in the NHS.

Feb
26

When I talk to managers and staff across the NHS, the question that I am most surprised to be asked is why I am so passionate about clinical leadership, and exactly why I think it is important for GPs to be commissioners.  I am surprised because the literature is unequivocal about the pivotal importance of clinical leadership.  But the reality is that many working in the NHS believe clinical leaders create more problems than they solve.

Taiichi Ohno (1912-1990) is widely regarded to be the father of the Toyota Production System, popularised as Lean Manufacturing.  He believed that managers could not manage if they did not understand the work place.  He was famous for drawing circles in the middle of the shop floor, and instructing managers to stand in them for days on end to observe what was going on and to understand the impact their instructions were having.

The complexity of healthcare makes it difficult for a single ‘workplace’ to be identified where managers can view the impact of their decisions, because patients have their own journeys that cannot be reduced to individual interventions.  Clinicians working within the system can however experience the impact of the decisions they are making.  NHS managers will never be able to truly appreciate the impact of their actions in the way that clinicians can.

Don Berwick, paediatrician and former President of the Institute for Healthcare Improvement and advisor to Barack Obama on health, asserted that the central premise of the health change debate was that only those who provide care (referring to clinical staff) can change it.  In the current financial climate it is even more important that those who understand the system make decisions about it.  The NHS Leadership website states, ‘Effective clinical leadership is critical if we are to achieve an NHS that genuinely has the quality of care at its heart’.  McKinsey have written an article, ‘When Clinicians Lead’, and state that, ‘Leadership must substantially come from doctors and other clinicians.  Clinicians not only make the front line decisions that determine the quality and efficiency of care but also have the technical knowledge to help make sound strategic choices about longer-term patterns of service delivery.’.

GPs were largely uninvolved in PCT led commissioning.  Practice based commissioning did not give GPs real budgets or real accountability.  That all sat with managers at the PCT.  Commissioning decisions are critical.  They determine where precious, limited NHS funding is allocated.  They set the strategy.  They determine which redesign projects are worth investing in and which are not.  GPs are uniquely placed to make these decisions.  They understand the needs of the patients they see on a daily basis.  They are often leaders within their local communities.  They experience through their patients the impact of changes to the health system.  There is no one better placed to lead commissioning.  There is no one more able to put patient needs at the heart of commissioning decisions.  It is not just important that GPs lead commissioning, it is essential.

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Jan
22

‘A good question is never answered.  It is not a bolt to be tightened into place but a seed to be planted and bear more seed toward the hope of greening the landscape of idea.’ John Ciardi

There are many questions that those involved with CCGs have.  These range from the most basic (e.g. what is a clinical commissioning group?) to the highly complex (e.g. how do I maintain practice engagement while meeting all of the authorisation requirements?).

Different people have different levels of involvement with CCGs.  The questions those leading CCGs have are different from those of the grass roots GPs, which are different from those working in a hospital, and which are different again from those simply looking in and wondering what is going on!

At CCG information we aim to provide opinions, discussions and debate based on a real understanding of CCGs for everyone who is interested.  So let us know what your questions are, the things that you are finding it difficult to understand, or areas that you want help with.  We don’t claim to have all the answers, but we do believe that by discussing the right questions we can play our part in enabling CCGs to be the force that they have the potential to be.

Contact us with your questions by email mail@ccginformation.com or post a comment below.

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Dec
30

Setting up a brand new Clinical Commissioning Group is not going to be easy.  And it is not a job for one person.  It will involve all the GP leaders, GP members, CCG managers, PCT Cluster managers, and partners from across the health and social care economy working together to make it successful.  This website will provide in depth, quality information and interpretation of everything that is required to make your CCG a success.