- Management allowance - This has been the burning issue of late with the arrival of the Department of Health's ready reckoner last month. This tool would ‘flush out' clinical commissioning groups (CCGs) that look unviable, said pathfinding network lead Dr Paul Zollinger-Read. Dame Barbara Hakin initially advised CCGs to work on the basis of £20 per head when using the ready reckoner to leave them some headroom. Dame Barbara's peers are stressing that this does not mean the eventual figure will actually be £20 per head and that the initial figure to be arrived at will still be within the range of £25-35 per head. The eventual magic number arrived at by the DH will have particular significance for smaller CCGs that face a bigger challenge to manage risk and don't have the benefit of economies of scale. Some PCTs and local authorities are also not pleased at the prospect of having to deal with more than one CCG, so the pressure is on for those who believe small is beautiful. A recent survey by the NHS Alliance and the NAPC of 128 GPs and managers working for CCGs found more than a third were being put under pressure to merge with other CCGs.One factor for the DH number crunchers to deal with is that CCGs will now commission 60% of services, rather than the original 80%. NHS Alliance chair Dr Mike Dixon said: ‘There's something like £60 a head available for commissioning. If GPs get £25 a head – which is the figure I'm hearing behind the scenes as well as in front – they'll be getting less than 50%, while the board gets £35 a head.'
- Public health budgets - Another factor DH officials will be working on is the public health budget that has to be siphoned off from PCT budgets and ring-fenced to be given to local authorities. This must be causing several headaches for budget setters. In its response to the Government's ‘update and way forward' document published in July, The Faculty of Public Health (FPH) said costs such as offices, IT and admin support had been overlooked, creating a 15-20% shortfall in the proposed ring-fenced budget. The FPH added that there are certain areas that are delivered by a ‘complex, interdisciplinary and interagency process', such as immunisation, sexual health, mental health and safeguarding, and public health for children (including school nursing and health visiting). The DH has pledged to publish shadow local authority allocations by the end of the year.
- Authorisation - A recent CCG event, jointly organised by the NAPC and NHS Alliance, best summed up experience on the ground of the authorisation process as extremely varied. Dr Amit Bhargava – co-lead of the NHS Alliance clinical commissioning federation, who led one of the workshops on authorisation – described the process as ranging from ‘supportive and facilitative through to the downright obstructive'. Another issue to be raised at the event was the issue of commissioning support, with a survey carried out by the NHS Alliance and NAPC indicating 46% of CCGs are restricted in the commissioning support they've been offered. Of these respondents, 60% said they were only being offered existing PCT cluster support. And with PCTs having input into the authorisation process, some CCGs might wonder whether a spurning of PCT commissioning support could affect their bid for authorisation.
- Clinical senates - It has been confirmed that clinical senates will not have a right to veto GPs' commissioning plans, but will help annually assess CCGs' performance. A letter last month to NHS chiefs from Dr Kathy McLean, the medical director of NHS East Midlands who chaired the NHS Future Forum group on clinical advice and leadership, said there will be about 15 senates in total and these will ‘not exist as statutory bodies or formal organisations', but instead will bring clinical leaders together to provide ‘a vehicle for cross-speciality collaboration, strategic advice and support to commissioners'. The original announcement that senates were to be introduced caused alarm among some GP leaders that they would stifle GPs' commissioning autonomy.
- PCT Debts - Policymakers have been adamant CCGs will not inherit PCT debts, but confidence on the ground appears lacking. A survey by the NHS Alliance and NAPC of some 128 GPs and managers working in CCGs found that two-thirds lacked confidence they would not inherit a PCT deficit. David Stout of the NHS Confederation believes the CCGs that will face trouble are likely to map closely with PCTs where there are legacy deficits: ‘If your PCT's in trouble, it's reasonably likely you will be too. From day one, some CCGs will be very challenged and some will be comparatively well-off.'
- Performance managing primary care -Earlier this year, the NAPC called for CCGs to manage primary care budgets, bringing the everyday GMS activity of GPs into the commissioning fold. It seemed something of a far-out idea at the time, but last month Professor Steve Field, former RCGP chair and head of the Government's listening exercise on the health bill, said CCGs should be delegated responsibility to performance manage primary care. And then Dame Barbara Hakin, in an interview with Pulse, said the same thing. Whether this will materialise into actual policy remains to be seen, but if it did it could have implications for local practice relationships with their CCG – with many of the former still showing ‘active apathy' on commissioning.
- Any qualified provider - This has proved to be one of the most controversial areas of the bill, but in July the DH put out a directive to PCTs that three mental health or community services must be provided under any qualified provider by April next year. The directive seems to have come out of the blue – when Practical Commissioning approached leading commissioning figures for comment, several said it was the first they'd heard of it. The move will allow for AQP to cover a further £1bn of NHS services, according to some commentators. AQP is limited, however, to only those services for which a tariff exists. A national tariff for mental health and community services is still being developed. A Q&A guide on AQP from the DH last month says commissioners will have to set the price if the service falls outside of national tariffs. This does not mean, however, that commissioners can negotiate prices with individual providers. Commissioners can select a model used elsewhere or work with local providers to decide what an appropriate price is and then commission the service under AQP.
- PCT redundancies - While some PCT staff are being made redundant as PCT clusters form, concerns are growing that CCGs will inherit remaining commissioning staff under TUPE – CCGs will then have to make them redundant and pick up the redundancy bill or keep them on as staff . TUPE will apply whenever a role that had been conducted within a PCT will still to a large part exist within the CCG.
- GP engagement - The number of GPs now signed up to a pathfinder has been cited as evidence of GPs' enthusiasm for the reforms by policymakers. On the ground, however, some are still arguing pathfinders lack a sufficient mandate. A recent Pulse investigation found almost three quarters of GPs on CCGs were elected unopposed. Last month BMA London passed a vote of censure in BMA chair Dr Meldrum for his ‘failure' to promote members' views and campaign for the withdrawal of the health bill. It was followed by a vote of confidence in Dr Meldrum by BMA council. The censure vote indicates, however, that there are still some GPs very opposed to this bill – including some senior BMA members.
- Deadlines - Despite all the above, the joint NHS Alliance and NAPC survey suggests two-thirds of clinical commissioners are still aiming to be authorised by April 2013.
The NAPC Annual Conference 2011 will provide updates on all aspects of the health bill reforms with speakers including health secretary Andrew Lansley and NHS chief executive Sir David Nicholson
