Posts Tagged ‘CCG’


Hello all!  Thanks for all the messages of support since my last post at the end of February, where I asked the question as to what next for the website.  Many of you contacted me directly with a number of suggestions, and many gave direct offers of help, and I really appreciate all of your input.

In the end I have decided to continue the blog with support from those with more technical capability than myself!  As a result the blog will now be hosted by The Information Daily ( ), which will provide a much better platform for both hosting and disseminating the content more widely.

Just for the record I still do not receive any form of payment or income for the blog, which is, and always has been, designed to support those working in and with health.

The first of the posts on the new platform is now live, and you can access it by clicking here.  It is entitled, ‘NHS cannot transform healthcare while defending the status quo’, and I argue that radical change may need to come from outside the NHS.

For the next few months I will post a message as a prompt that the new weekly blog is out.  Thank you for your continued support, and do let me know ( if you have any specific questions or topics you would like me to cover.





It was never going to be easy for CCGs, as membership organisations of GP practices, to be effective commissioners of general practice.  This has been brought into sharp focus by the planning guidance, which states this,

36. CCGs will be expected to support practices in transforming the care of patients aged 75 or older and reducing avoidable admissions by providing funding for practice plans to do so. They will be expected to provide additional funding to commission additional services which practices, individually or collectively, have identified will further support the accountable GP in improving quality of care for older people. This funding should be at around £5 per head of population for each practice, which broadly equates to £50 for patients aged 75 and over.’

The first thing to say is that no one was expecting this within the guidance.  And the result of this is, frankly, confusion.  There are a number of practices who understandably, because of the link in the guidance to the over-75s, have assumed that this funding is the replacement funding for the retired QOF points.  Interestingly I asked a number of individuals at a regional and a national level and none were clear whether there was a link between the two or not.  Eventually I found out from a senior member of the GPC that there is, conclusively, no link; the retired QOF points have been replaced by an uplift in the global sum.  But the confusion is important.  It is one conversation for a CCG to have with its member practices as to how the £5 should be invested when it is ‘new’ money; it is quite another when it is money taken off the practices via another route.

A further issue is the complication of timing.  CCGs are responsible for commissioning local enhanced services (LES) from general practice.  As from April these enhanced services can no longer be contracted for as enhanced services within the overall framework of the core GMS/PMS contract, but need to be contracted separately on standard NHS contracts.  Now, this might not be much of a problem in many areas, but in larger CCGs it is. 

This is because the legacy passed by historic commissioning organisations is often one of differential enhanced services being available within even relatively small geographical areas.  Through the passage of time, often going back 10 or 15 years, different deals were done in different places where different enhanced services were moved (or not) into MPIG or baseline or who knows where.  So what this means is that CCGs either have to decommission the service or make it available to all practices and potentially other providers. Neither are particularly attractive options. 

CCGs are accountable for improving quality and outcomes through effective stewardship of NHS resources, and at the same time are membership organisations of a collection of practices.  The reality of commissioning any service direct from member practices means that there will be occasions when the CCG has to make decisions that will be unpopular with some or all of the practices (because the decision negatively impacts upon the practices as businesses), because of its overriding duty to the population that it serves.  Decommissioning LES’s is one of these decisions.

So the question for CCGs (where this is an issue) is whether to link the decommissioning of existing LES’s with the £5 per head, or whether to treat the two completely separately.  The challenge is to ensure that, whatever decision the CCG takes, it is able to realise maximum value for patients for the money it invests.

A further issue is whether to set the expectation that the funding streams that are created are recurrent or non-recurrent. Paragraph 37 of the planning guidance states,

‘Practices should have the confidence that, where these initial investment plans successfully reduce emergency admissions, it will be possible to maintain and potentially increase this investment on a recurrent basis’

This is a fudge.  To create real change providers, whether they are practices or anyone else, need to take on staff and make them part of core business.  When funding is only available on a temporary basis how are organisations, particularly small organisations, supposed to effectively staff the new services?  CCGs need to be bolder and be clear whether the services they put in place are going to be commissioned recurrently or for one year only if they really want them to be successful.

And of course underpinning all of this is the need to transform general practice.  This is a key part of many CCG strategies for their local health economies.  We have considered previously on this site how this might happen (  The mandate to create funding of £5 per head of population is an opportunity to accelerate the transformation of general practice, and so consideration of how to achieve this has to form part of CCG thinking. 

So is the £5 per head of population an opportunity or a curse?  The money could provide the catalyst that is required to support the key role that general practice has within whole system transformation.  The challenge is whether CCGs can do this without losing their member practices along the way.

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

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

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

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

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

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

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

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

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

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

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If we carry on down the same road we have been down every previous year, with providers operating in isolation from other providers and CCGs operating in isolation from all providers, where will we end up?

If each organisation continues to develop its own plans then it plays out something like this.  Providers and CCGs enter the contracting round with the figures they need out of the contract.  They argue about the likely success or otherwise of demand management plans.  With the deadline imminent they agree a figure on paper, but they both take away different assumptions about what will happen during the year.  The CCGs assume demand will be reduced, the providers assume demand will grow. 

The net result is a deficit gets built in to the health economy position, because both build different assumptions into their forecast outturn position.  Someone will be right and so a deficit will inevitably sit somewhere.  The value of the agreed contract figure becomes material only in terms of determining the level of monthly cash payments.  In terms of establishing an agreed end of year position it is virtually meaningless.

In 2014/15 the gap between what CCGs can afford and what providers will require is going to be bigger than ever.  Aside from ever increasing demand and inflationary pressures, the situation is exacerbated by the planning guidance.  Now we have the cost of introducing seven day working, the requirement for CCGs to fund £5 per head for general practice, the need for CCGs to keep 4% out of recurrent expenditure (2.5% non-recurrent, 0.5% contingency, 1.0% surplus), just to name a few.

Once a figure is agreed on paper and the year starts, the cracks will start to appear.  CCGs facing financial challenges will shift down a route of increased contract challenges and reducing elective activity, and providers will try to do the reverse (improve coding and increase elective activity).  Throw in the last winter before a general election and the pressure will ratchet up, and relationships will become extremely fraught.  And if next year does not finish us off the year after will, with the transfer of funds from providers to social care via the Better Care Fund.

But there is an alternative.  We could work as health communities to have a single plan.  We could work together to take the resources that are available (knowing that they are insufficient) and use them collectively to deliver a single plan.  This requires each organisation to relinquish the sovereignty that it feels entitled to; actions would be determined by the greater good, not simply by what is best for any single organisation.

In this model organisations collectively commit to what the health and social care economy must deliver.  There is a single set of assumptions that all sign up to.  Agreement is made as to how the money will be used between the organisations in order to enable delivery of the plan.  The contract negotiations focus on this, rather than simply setting the level of cash flow. 

The alternative is harder to set up.  It requires providers to work with providers and CCGs to work with providers.  It will fail if alongside the one plan organisations have their own (secret? real?) plan.  Each organisation has to commit to the system plan.  Each organisation has to be accountable to each other for delivering their part of the plan. 

Clearly this requires trust between the partners. It introduces an uncomfortable interdependence.  If one organisation does not deliver, all will suffer because delivery of the overall plan will suffer.  And of course the worse the current position, and the longer we continue along the current course, the less trust there will be.  If we wait until we trust each other to do something different, we may never get started!

There is no doubt this alternative is harder to set up, but if we understand where the route we are currently on takes us then maybe we will think it is worth it.  After all, something has to change.

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Clinical leadership sits at the heart of the thinking behind the introduction of CCGs.  But as a result great expectation and great responsibility has been placed on the GPs who have taken on leadership roles in CCGs.

These are not easy jobs.  There are a number of complex elements to them that we have explored in previous posts on this site:

In ‘the importance of localities’ we established the need for those GPs leading localities to build the relationship with member practices,

‘The relationship between the CCG, with all its statutory responsibilities, and its member practices, with all the pressures they face, will be a critical success factor for the long term success of CCGs.’ 

In ‘8 top tips to drive GP engagement’ we identified that beyond developing the engagement of member practices a key role of GP leaders is to influence individual GPs, and that achieving this is no mean feat. 

Beyond that we determined in ‘CCGs are redefining out of hospital care’ that GP directors in CCGs have a key responsibility in the transformation of these localities around a redesigned general practice.

In ‘Is your CCG really clinically led?’ we established that GP directors have a corporate responsibility for the overall performance of the organisation and how it discharges its responsibilities,

‘An important question is whether the GPs on the CCG board are GP chairs – i.e. representing a specific group of practices or a locality – or are Clinical Directors.  The distinction is important.  A Clinical Director carries corporate responsibility for the organisation as a whole, including how areas such as finance and contracting operate.’

So in summary: build a relationship with practices, create an emotional connection between every member GP and the CCG, lead the transformation of general practice and community services, and take responsibility for the CCG hitting all of its statutory duties.

Can we expect our GP Directors to achieve all of this in 3 or 4 sessions a week?  Have we created undoable jobs?  Are we setting our GP leaders up for failure?  The public debate about GP directors has focussed on the potential for conflict of interests and how these are managed.  But it is missing the real question which is how realistic are the expectations we have placed upon these new GP Directors, many of whom have only been in these roles since April, and how are we supporting them to be successful?

And of course these GPs are primarily elected rather than appointed.  We give them the title of GP director, and then wait for the magic dust to descend and the great leader to emerge.  By and large it is sink or swim.  We are expecting leadership talent to emerge simply because they are GPs, without any structured development programme beyond that provided locally. 

There are examples of fantastic, courageous and highly talented GP leaders who are doing an amazing job and who provide inspirational examples of what is possible.  But how are we helping those for those learning the trade, who have taken on responsibility for leadership in the most testing time the NHS has ever known?  Doesn’t there need to be more: more structured leadership development, more visible support, more investment?  Isn’t this where we need those who are offering to support CCGs to focus their efforts?

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The Health Service Journal (HSJ) has this week declared that the ‘Oxfordshire battle will determine the impact of CCGs’ (here).  This is because, as the HSJ puts it, ‘One of the largest and most advanced attempts to bring about integrated, outcomes based commissioning has been delayed following objections from two powerful provider trusts.’

So is the HSJ right? The conclusion seems to have been drawn from what the events in Oxfordshire say about relative ‘power’ of purchasers and providers.  In the private sector different industries have different relative levels of buyer or supplier power.  In some sectors buyers (like supermarkets) wield great power and can drive price down.  In others (like the oil industry) suppliers wield the power and determine the price that buyers must pay.

So the HSJ argument is constructed on the basis that the formation of CCGs was to increase buyer power over providers, and that the amount of power exerted (in this instance the imposition of a specific contract) is the marker of CCG impact.

But there is very little about CCGs that is different from predecessor commissioning organisations that would increase their ‘buyer power’.  Maybe knowledge of services by the GPs and clinicians involved in CCGs, but at best there are only changes at the margins and certainly not enough to effect a significant switch in power.

I would argue that the whole notion of relative power is unhelpful for where we are in the NHS today.  The win/lose mentality between providers and commissioners has not served the NHS well in the past, and is extremely unlikely to help in the future.  It doesn’t help supermarket suppliers or those who buy oil.  And in the highly politically charged environment of the NHS, adversarial relationships inside the NHS will always damage the consistency of public message required to enable change to happen.

CCGs are most likely to be successful not because of an increase in relative power, but because of the ability of their clinicians to create partnerships with other clinicians and drive whole system change to improve outcomes. 

It is effective partnerships that are required, not power games.  According to Wikipedia, a partnership is, ‘an arrangement in which parties agree to cooperate to advance their mutual interests’.  And while it is tough to develop strong commissioner provider partnerships in the current environment, this is what is required. 

It is tough in part because the tight financial state of the NHS means there is limited funding to smooth the transition to any new model.  It is tough in part because each organisation has its own regulator putting pressure on it to take action that may be at the expense of partners.  And it is tough in part because people are not perfect, and in a pressurized environment any misplaced comment or action can quickly undo progress that has taken months to build.

The HSJ is being deliberately provocative in stating the ‘battle of Oxfordshire will determine the impact of CCGs’, but it raises an important challenge as to how we choose to monitor their impact.  Measuring whether or not contracts are imposed is not a good marker.  Any perpetuation of the win/lose mentality of provider commissioner relationships is unhelpful.  A much better marker is the ability of CCGs to form relationships that enable new ways of working that in turn drive improvements in outcomes.  Neither CCGs nor providers can make the changes they need for a sustainable future in isolation; it has to be done in partnership.

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

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

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

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

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

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

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

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



As we approach the precipice of the cliff, the pressure is on.  We look at the relentless tide of rising acute activity and everyone is clear, ‘something must be done!’.  In order for our hospitals to be able to restructure and organise services differently, experts and management consultants tell anyone who will listen that what we need is an ‘out of hospital strategy’.

But the NHS is changing. Out of hospital (as opposed to ‘in hospital’) is no longer the distinction that is helpful in framing the changes that clinical commissioning groups (CCGs) are striving to achieve.

Most CCGs are organised around some form of locality structure.  This is where groups of practices from the same area come together and operate as the underpinning infrastructure of the CCG.  In larger CCGs there may be up to 10 localities, and smaller CCGs may be made up of as few as one locality.  The principle however holds that practices are grouped in a rational way that makes meeting and decision making sensible and practical for the relevant practices.

A key question that many CCGs are grappling with is what exactly is the role of the locality in this post-authorisation world?  Initially the importance of localities was based on the engagement of practices in the CCG (which we have discussed on this site, for example here). 

But with the ‘call to action’ and the future of general practice becoming a live issue, the priority that CCGs are giving to the transformation of general practice, the introduction of the integrated transformation fund, and the murmurings about contracting general practice and community services together (here), the importance of localities is growing, and the role of localities is changing. 

Localities are now the focal point of the transformation of community based services around general practice.  The role of the locality is to bring the practices together into some coherent form of general practice provision.  This means a move away from, say, 6 practices operating in splendid isolation, to the 6 practices operating as one unit, and acting actively bringing together community services, social services and the voluntary sector.  There is no piece of NHS infrastructure better placed to support this change than the CCG locality.

This means the locality is no longer an arbitrary grouping of practices with collective responsibility for managing a budget, but is now the practical mechanism by which care for the local community will be organised and, dare I say it, integrated around local needs.  The crude separation of general practice as commissioner and general practice as provider is removed; the advantage of general practice as both is harnessed.

CCGs are redefining ‘out of hospital care’ as ‘locality-based care’.  It starts with the redesign of general practice.  It blends in community services and social care.  It adds any existing community estate.  It is all done in partnership with the local population.  And it can move at the pace of the quickest not the slowest; not all localities have to develop at the same rate.

Herein lies the biggest challenge and opportunity for CCGs.  There is no question this is a hugely difficult task.  But as membership organisations of GP practices CCGs are uniquely placed to make this happen, and if successful have the chance to make more of an impact on the design and delivery of healthcare than any predecessor commissioning organisation in the history of the NHS.

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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.



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.