Change at the coalface
We asked six CCG leads how they were progressing along the commissioning curve to authorisation, commissioning support and accountable officers
Our panel of six CCG leads were :
BT: Dr Bill Tamkin, shadow chair South Manchester CCG
SF: Dr Stewart Findlay, GP chair, Durham Dales, Easington and Sedgefield CCG
DS: David Slack, managing director, Somerset CCG
GP: Dr Gina Palumbo, chair, East Riding of Yorkshire CCG
JR: John Rooke, chief operating officer, Bedfordshire CCG
TB: Dr Tony Brzezicki. chair Croydon CCG
Which authorisation wave will you be part of?
BT Third wave for authorisation – we opted for second wave but they [the NHS Commissioning Board] didn't have capacity so the three Manchester CCGs are going for third wave.
SF Second wave. We did not feel ready for the first wave.
DS First wave as we are a CCG that has been working together for 12 months and have made good progress.
GP We chose to apply for first-wave authorisation as we have made steady progress with developing our organisation and we recognised the added impetus we would gain in ensuring our credibility via authorisation. Once authorised, we can focus all our resources on adding clinical value to service redesign and delivery of commissioning priorities across our health community.
JR First wave. We wanted to have more time to put things in place if any gaps arise. This will give us six months' head start to put them right.
TB Probably fourth wave, because we started as two CCGs and then had to merge. It all takes time.
What have you decided about commissioning support? Are you buying in end-to-end commissioning from a private organisation or PCT cluster or are you picking and mixing services to buy?
BT It's yet to be determined. We're waiting for the Greater Manchester Commissioning Support Service (GMCSS) to come up with an offer we can work with and see what they can do. So probably we will have a mix using the GMCSS when it's finally determined, plus some sort of sharing between the local CCGs in Manchester and some local work as well.
It's a fairly complicated picture in Manchester. We will probably commission services across the Manchester health economy, particularly in areas like mental health, safeguarding, communications, all the sort of things that lend themselves to a Manchester footprint.
Another component is that we have three big acute hospitals in Manchester and the likelihood is we'll be sharing and working together with the CCGs around those acute hospitals. At the moment we're not exactly sure how that will work but that's the idea. It'll mean sharing some of all the following – back office functions, performance, contracting and finance.
SF End-to-end North East Commissioning Support Service.
DS We have a service level agreement with Best West (the emerging Commissioning Support Organisation from Somerset and Bristol, South Gloucestershire and North Somerset PCT clusters). We are buying business intelligence and a number of other services but plan to undertake most provider management and pathway/service redesign in house.
GP We have a lean CCG structure and have agreed to buy many of our services from our local commissioning support service, which has recently passed check point 2 in its development process. We also plan to share some services with the local authority and neighbouring CCGs.
JR Greater East Midlands Commissioning Support Service (GEM) is committed to handle this by memorandum of understanding. It covers about 20 CCGs across the East Midlands and the Luton and Bedfordshire PCT cluster, purchasing predominantly HR, IT, informatics and so on.
TB We want to commission everything possible from the commissioning support service which will cover south-east London, Croydon and possibly south-west London. If we want economies of scale we have to go where the economies of scale are.
Who is going to be your accountable officer? Are they a GP or a manager?
BT It will be a management member. My concern about a GP taking on the role of accountable officer, apart from the huge amount of time and responsibility, is that our member practices may perceive it as having gone too far towards the dark side. In terms of leading the practices in South Manchester, I need to be one of them. My role is very much to lead our practices and get them all lined up around pathway redesign, acute contracts and so on, and I need to be able to see patients to be credible with them. If I had the accountable officer role that would be a bit more difficult.
SF Me. A GP!
DS It is planned to be a senior manager.
GP We plan to have a manager accountable officer and a GP chair.
JR It will be a clinician. We believe the CCG and accountable officer should be clinician led. We have yet to formally advertise it.
TB We have appointed a new borough director with a view to her becoming the accountable officer.
How is it going with your local health and wellbeing board?
BT We've had a number of development sessions since the end of last year with Manchester City Council. We've got representatives from the acute hospitals, mental health, CCGs and adult social services. It's chaired by one of the councillors. It's finding its feet. We're still working on the role and how it plays out with things like the Greater Manchester Health Commission. It has started, relationships are developing and we're moving it forward.
SF It's going well, established and we are working together.
DS The health and wellbeing board has been meeting on a regular basis in shadow form since October. There is an existing clear Joint Strategic Needs Assessment (JSNA) with a rich supporting shared database of health and social care information. A draft commissioning strategy has been produced. So overall progress is good.
GP We have had two formal meetings and a workshop with our health and wellbeing board, which has two GP members. Our health and wellbeing strategy is almost complete.
JR We are one of only four CCGs in the country to have two health and wellbeing boards because we straddle two local authorities. Both are led by locally elected councillors and in each case the chair is one of our local GPs. It's going well and the focus is on the things only we can do together.
TB We have a very advanced health and wellbeing board which has been meeting for well over a year now. It´s very well established.
Any developments on senates yet?
BT We're looking at them from a Greater Manchester perspective. It's one of the biggest clusters. We have a Greater Manchester council so the shadow chairs of all the CCGs meet on a monthly basis and we're looking to use that forum to take the senate forward.
GP We have not heard any news about clinical senates but are looking to work with other local clinical networks.
JR We have not heard a lot about this – for example who it will be hosted by. It has all gone quiet.
TB I think Dr Agnelo Fernandes (assistant clinical chair ) is going to sit on the senate. I'm sure it will be very important but we haven't been sent anything on it yet.
Once your CCG is authorised do you think it will commission more services under any qualified provider?
BT I don't have a fixed view either way. The driver my CCG has is very much around integration – I think the old primary/secondary divide is a false dichotomy. We're looking to improve quality for our patients across the whole pathway. We have a very vocal public patient advisory group which is very keen to work with its local acute trust. There are areas where we would be interested in commissioning other things.
Our CCG formed a social enterprise company three years ago and we've commissioned a minor surgery service in the community and a nursing home
service as well. I suspect we will be
looking at things like diagnostics further down the line. So AQP is in the mix
but it's not the primary driver.
DS No decision has been made and we would want to learn from the outcome of the first phase as to what has worked well or not so well and why. We are aware of the policy direction promoting the use of AQP.
GP There is a place for AQP to improve choice and capacity but the decision to procure via AQP should be needs led
and not simply to fill a quota.
JR We're looking at this on a case-by-case basis. In some areas we´ll want to integrate provision, for example elderly patient care, but in other cases, planned care will be more suitable for AQP. We're undertaking it in three areas currently and I imagine we'll be asked by the NHS Commissioning Board to take on more next year.
TB Definitely. We've already done one for cataract surgery and are now considering a specification for urology and potentially other services too.
Are you worried about being challenged by providers on commissioning decisions/tenders in the future?
BT One of the things that has happened here is that there is a critical mass of primary care clinicians who have quite a loud voice about what should and shouldn't happen. I suspect there will be some discussions and tensions around what's commissioned and we probably need to start to think about aligning our strategic priorities with the acute trust hospitals.
One of the challenges is that we have three large academic teaching hospitals in the Manchester footprint and they are keen to attract more tertiary work. We're very keen to dovetail into that and pull out the district general hospital-type work – the chronic disease management that can be done in the community.
I think there will be some tough negotiations but I think we're all aiming at the same thing. We need to try and make sure that our acute hospitals take notice of the JSNA and the public health priorities that we have for our patients. There will be some horse-trading and some tit-for-tat going on but the relationships here are pretty good.
DS We are aware of this risk and the need to ensure robust evidence and processes when reaching decisions.
GP This is definitely a risk and the CCG must ensure we have robust and transparent commissioning and contracting to minimise the risk.
JR We're not anticipating any challenges. We work closely with with the competition panel where we believe there might be a problem.
TB I would see that as a normal course of events. I'm quite sure not all providers will be happy with every decision. We're working hard to have good relationships with all our providers. I'm ever the optimist.
Does your CCG envisage having a performance management role of primary care? If so, has it done anything to get the ball rolling?
BT Officially the answer is no, but if you're trying to improve quality around patients' pathways that's not just about discussing issues with the acutes but also about discussing issues with your colleagues in primary care. So we performance-manage them in the sense that we meet as an organisation every quarter, we have patch meetings, we have benchmark data looking at prescribing rates, referral rates and use of diagnostics. They have to work within a budget and where there is under-performance or over-performance, we will challenge.
But it's not a contractual performance management role apart from the fact that we do currently have a social enterprise/IPS-type agreement between us and the practices that requires them to work in a more corporate manner. It's fairly loose but it does tie them into the way we want to direct things so performance management has happened by default.
SF Yes we have a director of primary care development and quality who is a GP.
DS We do not envisage performance management but will be working to improve quality.
GP Primary (and community) care are being asked to deliver much more as we move ‘care closer to home' and we recognise that this must be properly planned and resourced. We are working with our practices, neighbouring CCGs, the local deanery and LMC to understand how this can be best realised.
JR Yes. We believe it's our fundamental duty to improve quality in primary care. We have a primary care quality framework, a sophisticated tool that examines general practice and allows a broad, holistic 360-degree look at lots of quality measures – including what partner organisations think of general practice locally.
In statute CCGs have very little leverage. Our only tool is to appeal to people's professional integrity via peer review and support. Fortunately the quality of our practices is very good.
TB It's not our job to manage the poorly performing doctor. But we have got the responsibility of treating a population of patients and to make sure the quality of that treatment is high for all of them. That means we will be discussing issues that arise and challenging practices to maintain that quality.
What would you say is the next big issue for your CCG?
BT The big issue for us at the moment is authorisation. We have a huge amount of work to do. Although we're going to be third wave we are working to the deadlines of the second wave to get the job done.
The big issue currently is around capacity. We are non-statutory organisations and responsible now for the absent PCT's statutory role. At the same time we continue to see patients and try to get ourselves ready for 2013. We don't have any contracts, holiday pay, sick pay. They're asking GPs to step up to a big responsibility without any resilience or security in the HR process so that's what's exercising my mind currently.
From a clinical point of view, we have loads of issues. We have all the health problems you'd expect in a big conurbation like Manchester – COPD, CVD, mental health. We have to get commissioning support sorted out.
DS Community services.
GP Our priorities are healthy ageing, reducing inequalities with a particular awareness of the wider social determinants of health and also improving the health and well being of children and young people.
JR We're managing more and more in primary care. The rising tide of specialisation means we're looking at reform not just of acute care but of primary care over the next 10 years, so we take radical solutions to the public. Local areas will start to attract services so that we can cope locally instead of sending patients to London as we look to develop networks of teams rather than individual hospitals.
TB For us, it's all about process – authorisation, moving to commissioning support services.