User:Nikkismiton/Clinical commissioning groups

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Introduction[edit]

Clinical commissioning groups (CCGs) were established under the Health and Social Care Act 2012^[1] to be responsible for the commissioning of primary health services in England. Commissioning is the process by which needs are defined, priorities determined and appropriate services purchased and evaluated.^[2] These responsibilities are currently held by Primary Care Trusts (PCTs) and will be transferred over to CCGs by the deadline of April 2013.

The Health and Social Care Bill originally proposed that commissioning solely be undertaken by GPs. The groups responsible for this were at this time referred to as GP consortia.^[3] Following the completion of the government’s ‘listening exercise’ in June 2011 this structure was modified. The independent commission who called for the pause, known as the NHS Future Forum, felt that the pace of reform was too quick and that the membership of the groups did not promote collaborative working, stating that GPs: "cannot and should not do this on their own and must be required to obtain all relevant multi‐professional advice to inform commissioning decisions and the redesign of patient pathways".^[4]

CCGs are still based around GP practices, but incorporate wider professional involvement and engagement with other health and care professionals, patients, carers and the public. The governing body of each CCG includes at least one registered nurse, and one secondary care specialist doctor, with the aim of promoting joint working and accountability.

There is a history of GPs having a role in commissioning, going back to the 1990s concept of GP fundholding.^[5] This allowed GPs to hold real budgets with which they purchased primarily non-urgent elective and community care for patients. The Labour government under Tony Blair abolished GP fundholding, but retained the purchaser/provider split as part of the practice-based commissioning^[6] (PBC) initiative. PBC encouraged ‘virtual’ budgets to be placed in the hands of GP practices to make commissioning decisions in partnership with PCTs.

Purpose[edit]

The intention behind CCGs is to give doctors a greater role in financial and strategic decision-making in the NHS, in order to exploit their in-depth knowledge of the needs of their local populations. The coalition government introduced this idea in their 2010 White Paper 'Equity and excellence: liberating the NHS': "in order to shift decision-making as close as possible to individual patients, the Department [of Health] will devolve power and responsibility for commissioning services to local consortia of GP practices. This change will build on the pivotal and trusted role that primary care professionals already play in coordinating patient care, through the system of registered patient lists"^[7].

The White Paper deemed previous attempts at introducing GP commissioning as unsuccessful: "fundholding led to a two-tier NHS; and practice-based commissioning never became a real transfer of responsibility. So we will learn from the past, and offer a clear way forward for GP consortia"^[7].

Once authorised (see section 5) the main role of the CCG is to assess local needs, plan what services are required to meet those needs, and then to procure those services on behalf of patients. Services that will be commissioned by CCGs include urgent and emergency care, out-of-hours primary medical services, elective hospital care, community health services, and rehabilitation, maternity, mental health and children's health services.^[8]

Duties[edit]

The Commissioning Cycle

General duties of CCGs include the use of population data to ensure continuous quality improvement, and to reduce inequalities in access to and outcomes of health care. Planning duties involve contributing, with local authorities and health and wellbeing boards, to joint strategic needs assessments and health and wellbeing board strategies. CCGs will also co-ordinate care across health and social care^[9].

In-depth commissioning duties will range from sourcing complex population level data required to inform commissioning decisions, to specyifying and managing ongoing contracts. Once a contract is in place, CCGs will need someone who understands the contract and is able to performance manage it so as to ensure that outcomes are achieved and KPIs monitored. CCGs are also responsible for the development of joint commissioning arrangements with groups in other areas in order to promote efficiency.

CCGs are also required to foster and incorporate patient and public involvement (PPI) in the planning of commissioning arrangements and in developing, considering and making decisions on any proposals for changes in commissioning arrangements that would have an impact on service delivery or the range of healthcare services available^[10]

The monitoring and improvment of the quality of primary care will also be undertaken by CCGs in order to support the NHS Commissioning Board. Groups will provide information to other bodies, such as the NHS Commissioning Board, Information Centre, Care Quality Commission and others as required, review access to services, and identify poor performance at practice level^[11]

In practice this means commissioning healthcare as necessary to meet the requirements of patients registered with GP practices within the CCG, and those who live within the CCG’s defined geographic area but are not registered with a GP practice.

Other groups served by CCGs will be those present in the group's geographic area who require emergency care, and those receiving NHS continuing healthcare in out-of area placements.

CCGs are obliged to act consistently with the duties of the Secretary of State and the NHS Commissioning Board to promote a comprehensive health service and the objectives and requirements set for the NHS Commissioning Board by the Secretary of State through the mandate.

Structure[edit]

Structure of CCGs[edit]

There are set to be 212 CCGs, as announced by Dame Barbara Hakin, National Director of Commissioning Development, on 28th May 2012.^[12] The full list of proposed configurations and member practices was made available shortly after this via the NHS Commissioning Board.^[13]

There will be no minimum or maximum size, but the NHS Commissioning Board must be satisfied a group’s population is appropriate. Every GP practice will be part of a commissioning group and legislation will ensure practices cannot operate if they do not join a group. Every CCG must also have a governing body or board that will have decision-making powers. This must include at least two lay members – one with a lead role in championing patient and public involvement and the other with a lead role in overseeing key elements of governance. One of the lay members will either be the chair or the deputy chair of the governing body. The governing body must also include at least one registered nurse and one doctor from secondary care, although in order for there to be no conflict of interest these individuals must not be employed by a local provider. Governing bodies will be required to meet in public and publish the minutes of their meetings.

The NHS Commissioning Board will consist of 27 local area teams. All LATs will be involved in overseeing CCG development and performance and commissioning primary care or more specialist services. Some LATs will also be involved in acting as hubs for commissioning specialised services and hosting clinical senates and networks. They will be overseen by 4 regional offices which will hold CCGs to account on measures in the Commissioning Outcomes Framework, based on NICE advice.^[14] The board will intervene if CCGs begin to fail. It will also issue guidance on financial risk management.

Structure of the new NHS[edit]

Other bodies that CCGs will work closely with are:

Clinical senates - 12 regional clinical senates across England will be aligned with NHS commissioning board local area teams and Deaneries. The senates will provide cross-specialty advice to CCGs and HWBs, as well as links with 4 national clinical networks (CVD, cancer, mental health and children and maternity). They will bring together doctors, nurses and other professionals including public health and social care experts to advise on significant service changes and reconfiguration.

Clinical networks - Clinical networks will bring together experts in specific clinical specialties, including patients and carers. These networks are likely to help CCGs decide how best to reconfigure services in a specific specialty and help them establish their commissioning priorities. Both the clinical networks and clinical senates will be ‘hosted’ by the NHS Commissioning Board, rather than being new organisations.

Health and wellbeing boards - Health and wellbeing boards are structures that will sit between local authorities and commissioning groups. They will also have a 'formal role in authorising' CCGs to become statutory organisations. Although CCGs will be represented on health and wellbeing boards, local authorities will control their make-up. Commissioning groups will be expected to involve health and wellbeing boards throughout the process of developing commissioning plans. Under statutory guidance, CCGs will be required to develop plans in line with the health and wellbeing strategy and health and wellbeing boards will have the right to refer commissioning plans back to the NHS Commissioning Board if they feel they do not meet this requirement.

HealthWatch - HealthWatch England will be set up as a new patient representative organisation to provide patients and the public with a voice at national level. Local HealthWatch groups, which will replace current local involvement networks (LINks), will scrutinise local commissioning.

Monitor - Following the listening exercise, Monitor’s role has been changed and its core duty will now be to protect and promote patients’ interest. It will be required to support the delivery of integrated services and ensure that competition is fair and operating in the interests of patients. Monitor says it will ‘tackle specific abuses and restrictions that act against patients' interests, to ensure a level playing field between providers.^[15]’ Monitor will investigate any complaints about CCGs acting anti-competitively, but it will not performance manage commissioning groups.

This diagram shows how CCGs will fit into the new NHS structure.

Authorisation[edit]

Authorisation is the process through which CCGs are deemed ready and able to take statutory responsibility for the commissioning budget.^[16] Most CCGs are expected to take control of budgets from PCTs by April 2013, with shadow CCGs being set up across the country by GP practices in preparation.^[17] There will be four waves of authorisations for prospective CCGs, with four corresponding deadlines for submitting applications.^[18]

The Department of Health published a letter on the authorisation process which states that: "In order to become statutory bodies, CCGs will need to be formally authorised, and local government and their partners in health and wellbeing boards have an important role in that process".^[19] The accompanying set of slides outlines the six domains that draft applicants must meet in order to become authorised successfully.^[20]

These applicant guidelines work on principles previously agreed in Department of Health guidance which introduces the concept of authorisation based on six domains. These are: a strong clinical and multi-professional focus which brings real added value; meaningful engagement with patients, carers and their communities; clear and credible plans which continue to deliver the QIPP challenge within financial resources in line with national requirements and local joint health and wellbeing strategies; proper constitutional and governance arrangements, with the capacity and capability to deliver all their duties and responsibilities, including financial control, as well as effective commissioning; collaborative arrangements for commissioning with other clinical commissioning groups, local authorities and the NHS Commissioning Board as well as the appropriate external commissioning support; great leaders who individually and collectively can make a real difference.^[21]

Accountability[edit]

CCGs will be held to account in a variety of ways. Their primary, formal line of accountability is to the NHS Commissioning Board. As a public body they are also accountable to their local population. Their strategic alignment with their local health and wellbeing board will facilitate public accountability. CCGs will also be expected to demonstrate public and patient involvement in their decision-making. There is a mutual accountability between the CCG governing body and its member practices; the governing body will need to hold practices to account for individual commissioning decisions, while demonstrating to member practices that it is adhering to the common purpose and values in its deployment of resources and operations.^[22]

Figure 1 of the 'Good governance for clinical commissioning groups' report^[22] demonstrates the lines of accountability and funding within the new NHS structure.

Emerging CCGs will need to demonstrate as part of their application for authorisation (see section 5) that they have robust governance arrangements, including arrangements for transparency in decision-making and for dealing with potential conflicts of interest. These should include: involving of patients and the public in their commissioning arrangements; including of at least two lay members on their governing body, one with a lead role in championing patient and public involvement, the other with a lead role in overseeing key elements of governance such as audit, remuneration, and managing conflicts of interest; keeping up to date registers of interests that are made available for public scrutiny; setting out in their constitution the way in which decisions will be made, and how decision making will be transparent; holding meetings of their governing body in public, except where it would not be in the public interest to do so; and holding an annual public meeting to present their annual report. These must be set out in the CCG constitution.^[23]

The NHS Constitution also containts a statement of accountability which applies to the NHS as a whole.^[24] This will hold CCGs to account in a more formal sense.

Support[edit]

At present, commissioning support is undertaken predominantly by NHS staff working in PCT clusters. Staff are working to develop sustainable independent models of commissioning support which will be made available to CCGs in the future. In some instances, especially in larger CCGs, elements of commissioning support will be delivered in house. In other cases, one CCG may host a service on behalf of other CCGs. Some services may be delivered through staff led enterprises or joint working arrangements and joint ventures with local authorities or the independent or voluntary sector.^[25]

Commissioning support units (CSUs), until reccently referred to as commissioning support services (CSSs) will support CCGs with various aspects of commissioning such as: business intelligence; analysing health needs and demographics of the local population; negotiating and managing contracts; and engaging with the local population and other local stakeholders in order to lead change and service redesign from April 2013. Other duties include: identifying gaps in services; spotting and managing risks; identifying service providers; managing tendering; negotiating contracts; and providing administrative support to CCGs. There will be 23 CSUs, formed largely from ex-PCT staff, set up as free standing organisations which sell their services back to the NHS. The NHS Commissioning Board has been charged with setting up and hosting CSUs to help CCGs function until 2016. After this CSUs will become independent commercial organisations. Many of the CSUs already in operation have been achieved through the public and private sector working together. This support, particularly from the independent sector, tends to be in the form of specific tools and processes rather than delivering the whole commissioning process which pulls together all elements of support.^[26] Reference behind HSJ paywall...wanted to refer to Commissioning support services: key facts from NHS Commissioning Board but link is now broken

The NHS Commissioning Board have said that given the new focus on quality and outcomes for patients across the NHS, and the need to get the best value from NHS resources to meet the productivity challenge, CSUs will need to focus on supporting delivery and being effective in combining or networking services across a broad geography.^[25]

The last business review checkpoint that applicant CSSs were submitted to in May 2012 (before the change in name came into force) sought to assess viability. 13 potenital CSSs passed this checkpoint successfully, 9 CSSs passed with concerns that required rapid attention and 3 CSSs did not pass.^[27]