Dr Carl Ellson has focused on creating a bottom-up culture at his CCG. Here he answers questions on engaging with fellow practices.
South Worcestershire clinical commissioning group spreads for more than 50 miles, covers 31 practices with a registered population of 287,000, and has a commissioning budget of £300m. I have been clinical lead since its inception as a practice-based commissioning clusterin January 2008.
Inclusiveness and a ‘bottom-up’ approach to commissioning have been key components of the culture we have attempted to foster over the last four years.
How do you ensure all practices get a say in commissioning?
Engagement in commissioning is a joint responsibility between the CCG and individual practices. It is time consuming to do it well, but more than worth the investment.
We are only going to realise the benefits of clinical commissioning if we achieve a widespread understanding in the member practices. We have adopted a number of strategies towards this end:
• SWCCG is structured into four localities with between four and 11 practices in each. There is a monthly meeting of each locality chaired by the locality lead (an elected GP) and attended by one GP and the practice manager from each practice. This structure facilitates a regular dialogue between the CCG management team and the individual practices. The meetings act as a mechanism for exchanging information between the practices and the CCG board. They also develop commissioning schemes in response to local needs and pilot approaches before rolling them out across south Worcestershire.
• We reinforce the message that a key role for commissioning GPs and practice managers at locality meetings is to act as the conduit between CCG and practices. Some fulfil this role diligently and provide a detailed commissioning briefing at practice meetings. Others are less conscientious.
• We are pragmatists, so in recognition that not everything will be fed back to all practice staff as we would like, we use roadshows to take information to practices and to enable the CCG to listen to practice teams. A year ago, we took a presentation on the Government’s white paper and the Health and Social Care Bill to all 31 practices to explain the scale of the reforms, the financial environment and the implications for primary care and commissioning.
This direct engagement was welcomed by practices and a year on we are about to embark on a second round. We have also found that going into practices to discuss major service redesign projects is time well spent. A separate round of roadshows was used to support the introduction of integrated clinical assessment and treatment services (ICATS) for orthopaedic referrals.
What aspects of commissioning is it appropriate to delegate to practice managers?
We have found practice managers an invaluable source of commissioning support. GPs and other clinicians are needed for their clinical knowledge of services, pathways and redesign opportunities, but we firmly believe that clinicians’ expertise is best used when they work in tandem with a manager, not least because the latter are less expensive.
We use development days for all our practices to work up commissioning priorities, which feed through to work programmes. In allocating commissioning projects, we attempt to match a clinician to either a practice manager or CCG manager to take forward the work. We have found that this team approach delivers the best results.
Practice managers also have a key role in the implementation of change. This may take the form of the introduction of a new local enhanced service or the diversification of service providers.
Recent examples for us have been the re-organisation of physiotherapy services following a procurement exercise, introduction of a nursing home LES and the management of QOF/QIPP, which has required co-operation between the PCT, the CCG and practices. Practice managers are the lynchpin who ensure that everything comes to fruition in a timely manner.
It is also worth remembering that practice managers come from very varied backgrounds, with different interests and skills. We have found that by getting to know them all well, they collectively can make a fantastic contribution to commissioning. Depending on the commissioning issue, we would call on different individuals for help with business case development, finance, IT and patient and community engagement.
How much should practices be reimbursed for their work on commissioning?
I regard it as the responsibility of the CCG to specify the time requirements for GPs. Each of our 31 practices nominates a GP to sit on their locality group. The CCG reimburses the individual GP or the practice (depending on internal practice arrangements) for one session per month. For this, the GP is expected to read agenda papers, attend the locality meeting of two to three hours’ duration and perhaps follow up a few small actions. Meetings are scheduled on an annual basis so the dates are known to practices well in advance.
Further work is accommodated by separate negotiation.
Again, it is for the CCG to scope the time commitments for a board member and to make these known to practices. In addition to myself as clinical lead, we have six GPs who have been elected to sit on the board. Their commitment is for four sessions per month. Most have taken on additional work over and above this commitment and we hold a clinical contingency fund to enable us to pay for this additional involvement.
How do you use the specialist clinical skills of GPs in your area for commissioning?
The CCG has a number of time-limited projects on the go at once and for these we put out requests for further GPs to help and fund this work on a sessional basis. Some of these projects, such as orthopaedic ICATS and urgent care reconfiguration, have required considerable input – perhaps one session per week for a year and more.
Other pieces of work are far more limited, such as buddying systems with consultants to review aspects of a particular specialty.
We advertise these opportunities through a weekly email briefing that goes out to all our practices, and generally receives a good response.
We recognise that we have a wealth of experience and diversity of interest and skills within our GP population. Twelve months ago, we wrote to all our practices asking them to respond with the interests and specialist skills of all their GPs so that we could approach individuals to support specific projects.
From this approach, we sourced our urgent care lead and the four GPs who sit on the liaison board with our local acute provider.
This approach also flushed out a salaried GP (now a partner) whose enthusiasm resulted in him being elected as one of our locality leads and a board member.
As new commissioning priorities emerge, we intend to use this mechanism to source additional support from our GP population.
Dr Carl Ellson is clinical lead for South Worcestershire Clinical Commissioning Group, and a GP in Droitwich Spa, Worcestershire