Editor Sue McNulty asks commissioning supremo Dame Barbara Hakin how GP commissioners will be expected to work with the NHS Commissioning Board, clinical senates and health and wellbeing boards.
How will the NHS Commissioning Board with its 3,500 staff rise to the challenge to reduce bureaucracy in the NHS?
There is a range of things the board can do that will now be able to be done once, rather than in previous years where we had several layers of organisation. Its relationship [with clinical commissioning groups – CCGs] will involve developing them and supporting them but also ensuring they're fit for purpose.
The numbers of individuals doing that will not be huge in comparison to the numbers of people on the board. What's important to remember is that the board is also responsible for a significant amount of direct commissioning itself, such as specialised commissioning, and will have several hundred individuals undertaking this, although significantly less than [current numbers] in line with management reductions.
The category that causes the huge numbers of staff is primary care commissioning, which includes not just primary medical services but dentistry, optometry and pharmacy.
At the moment, there are many, many thousands of staff involved in primary care commissioning, either in PCTs having a direct relationship with the GPs or many, many more in what used to be known as FHS functions – doing back-office pay and ration functions for all those organisations.
I do think that when people see the board numbers they think ‘gosh, what an enormous organisation, this is going to be enormous bureaucracy'.
Well it is an enormous administration because we shouldn't underestimate the amount required to make sure that doctors, dentists, optometrists and pharmacists get paid, but the bulk of staff in the board will be doing primary care commissioning.
Obviously all these changes we're discussing are subject to passage of the bill.
How will the board differ to a PCT or SHA? The dynamic between PCTs and GPs is often constrained PBC. How will the board avoid falling into the same trap?
The whole concept is different from PBC. PCTs were the holders of the budgets and the statutory organisation and they devolved or delegated to practice-based commissioners. The statutory organisations here are the CCGs and the only other statutory organisation that exists is the NHS Commissioning Board.
In order to have a relationship with its CCGs, both in terms of support and innovation and developing them, it wouldn't be appropriate for all the people who work for the board to be in one location. But in the past in the NHS we've always had different tiers of decision making – the PCTs and SHAs have had a board and been independent statutory organisations making decisions for their patch. That won't be the case with the NHS Board. It's one organisation but it will have people based locally in order to allow them to have the right local relationships. The board's relationship with the CCGs will be the same whichever and whatever the CCGs are.
The current SHAs have an oversight of provision of services, whereas there is an expectation that provider organisations will become foundation trusts and will become independent. The offices of the board across the sectors won't have a board, there won't be an independent statutory body making decisions – they will be a local manifestation of the board itself.
Do we know how many clinical senates there will be?
Sir David Nicholson has already said that he expects there to be about 15 clinical senates, so these are quite high-level bodies covering a broad geography. The idea of clinical senates is that they can be a source of advice to the NHS Commissioning Board and the CCGs and I would imagine that a significant role for them would be advice to the board on specialised commissioning.
They're also there to be a source of advice to CCGs if they should have issues where more generic advice is needed. This is different to the networks which will look at individual pathways. The senates will also be able to give an external view where it is more difficult for local clinicians to give a specific view because they're so involved in the services themselves.
But GPs would say: ‘We know our patients and we know our local services.' What does the clinical senate bring to the commissioning table?
When you're doing major service redesign it's important to have senior clinical professionals of all kinds, not only doctors but also nurses and those people who understand specific aspects of services. There are times where a reconfiguration isn't about one service, it's about several services which if you change have a knock-on effect on the material shape of services across a whole region.
And having the benefit of the advice of a range of clinical professionals who can look externally at whether what you're proposing makes sense, meets the evidence of what is best practice, will provide a gold standard service. It may be particularly important where local clinicians, from whom the GPs are commissioning services, might have a conflict of interest, so it could well be about their local services whereas a clinical senate will be able to give that much broader overview. They bring an experienced, objective, professional voice.
The issue about reconfiguration is often about secondary care rather than primary care. So if there were several providers and you were having to rationalise their care the clinical senate might not have a conflict of interest there. [CCGs] don't have the funding for primary care services, which is why they don't have a conflict of interest on the governing body of their own organisation whereas a secondary care clinician would have a conflict of interest because that CCG has the budget to buy in secondary care.
But there will also be instances where CCGs want to shift care – secondary into primary care or the community – then they may well have their own interests as a provider. So we need to work with pathfinders and CCGs to find out exactly what can be done to deal with that to ensure it doesn't breach the rules of good governance.
The clinical senates are allowed to have consultants from local providers though?
The clinical senate is an advisory body and a conflict of interest doesn't arise if you're an advisory body.
For the enthusiastic GP commissioner, with the enhanced powers for health and wellbeing boards, the new clinical senates, might be feeling their power has been diluted?
Sometimes when there are difficult decisions to make, a body of opinion that represents people and understands why you've made that decision might be enormously helpful. Let's remember too that CCGs are on the health and wellbeing boards. It's not as if the two are entirely separate. And to be honest, if you can't convince that group of people that what you're doing is in the best interests of patients then I think it's worth doing what the bill now suggests, which is the health and wellbeing board asks the CCG to reflect. But that does not stand in the way of the fact that the CCG is the accountable statutory body which – in the final analysis and on the basis of its discussions with the health and wellbeing board – has to determine how and what services it delivers for patients.
I don't think we should see the clinical senates as separate from the NHS Commissioning Board. These are not statutory bodies, they don't exist in their own right as independent organisations. They are simply groups of clinicians brought together and supported by the board to give advice to itself and the CCGs. There will need to be no primary legislation to support them.
When might CCGs not be authorised – or lose their status?
The bill makes it clear that CCGs will have an initial authorisation and then an annual assessment. By April 2013 we will have comprehensive coverage across all of England of CCGs. The authorisation process determines whether they're fully established or established with conditions so some CCGs before April 2013 could be fully established without any conditions and ready to commission all [their] services.
Some, I'm sure, will be established with conditions and that could look very different across different CCGs. So for some, the conditions might address organisational immaturity, where you have a CCG where there wasn't absolute certainty that all its financial arrangements were appropriate. So the board could authorise with the condition that it got additional financial management support for a short while until its own arrangements had bedded in.
Or you might have a CCG whose overall organisational arrangements are fine but there are certain slightly more complex services – not specialised services, because those would be done by the board – but more specialist-type services where it was felt the CCGs around it weren't yet ready to undertake those services. So the board could establish the CCG with the condition that it didn't commission those particular services and the board would commission those on an interim basis.
There is a third category and that is established with the condition that you're effectively operating in shadow form, which if you remember was noted in the response to the future forum.
So those CCGs that just felt either completely unready to take on any commissioning functions or alternatively if – and I hope this is extremely unlikely – the board felt the CCG was really not ready to undertake anything, the conditions in the early stages of the establishment was that the board would undertake the commissioning group's functions or another CCG would do so on their behalf.
So is it a pick and mix? Can you approach the NHS Commissioning Board and say: ‘We're ready to do diabetes, but actually would like to do, say, maternity services, next year?'
The bill has made it very clear from the beginning that CCGs could ask the board to undertake any commissioning on their behalf. So it could, as you say, be a pick and mix of services. Quite often for services much of it is about the organisational infrastructure and often there are a lot of services from the local hospital that are interlinked.
I would imagine most clinical commissioners would want to take on most of those but certainly if a commissioning group didn't want to undertake something like maternity or ambulance services then it could ask the board to do it. On the other side of the coin, if the board didn't think the CCG was ready to commission those services even if the CCG wanted to, it could establish with conditions that those services would be undertaken elsewhere.
Our aspiration – and Sir David has made this very clear – is that where CCGs want to be authorised, we should be putting all our support around them over the next 18 months to ensure they are fully authorised if they want to be by April 2013. That's the ambition, where a CCG wants to be authorised then we should do everything we can to make that happen by April 2013.
We will certainly define under what criteria CCGs could be established without any conditions. But in essence this is part of a journey of development and it isn't easy for us to say, well, it's a, b,c, d and e or else you're not authorised, because for all of these things it's a question of degree – how far away you are from the desired level of competence, what sort of plans you have in place to reach that level,what degree of confidence is there that you'll be able to put those plans into place.
Click below to watch an excerpt from the interview.
Dame Barbara Hakin is the national managing director of commissioning development at the Department of Health
