CCGs are free to determine their own structure however they see fit. The only conditions on them are that they must have two committees: the governing body and its audit and remuneration committees, which are mandatory under the Health and Social Care Act 2012. This article summarises the typical models adopted by CCGs, identifies the relevant provisions in a CCG’s constitution that governs its structure and the roles of those involved, the implications for GP practices as members and how members can effectively participate in their CCG.
Although CCGs are free to determine their own specific structure, there are generally three models, which I have termed:
- Open – This is a CCG with a lot of active member involvement and participation, usually through a council of members. In this model a lot of decisions are either reserved to the members or the council is consulted by the governing body before a decision is made.
- Closed – All, or a significant proportion of, the decisions are delegated to the governing body and the body has not been widely expanded to include a significant number of GP member practice representatives. This is probably the most comparable model to the PCT structure, where the scope for active involvement of member practices is more limited.
- Grassroots – here, most of the decision-making is delegated to the governing body but committees of the body are established (commonly referred to as ‘locality committees’) to provide feedback from each locality on commissioning issues. Whilst such committees can be tasked with taking commissioning decisions in their locality, they remain committees of the governing body, not of the wider membership.
It is important when considering the structure of a CCG to distinguish between a committee of a CCG (i.e. the members) and a committee of the governing body. A committee of the CCG is a committee of the members whereas any committee of the governing body reports back to the governing body and not to the members. Please see the structure diagram below, setting out the typical structure of a CCG.
How to determine your CCG’s structure
Most CCGs have prepared a structure diagram setting out the committee structure of the CCG and this is the quickest and easiest way of getting a “snapshot” of the CCG structure. This is usually available from the website of the CCG or from a member of the governing body.
If more detail is required, the constitution sets out the governance and committee structure. Most, if not all, CCGs have adopted the NHS Commissioning Board’s Model Framework constitution and, accordingly, the numbering of constitutions is consistent across the country (there may be minor variations as some of the sub clauses are optional). Accordingly, to determine the organisational structure of your CCG, you should focus on the following sections of the constitution:
6.4 Committees of the CCG (Members):
This will set out any committees of the CCG, such as a Council of Members. However, if clause 6.4 is headed “joint arrangements” then this section has been omitted and there will probably be no committees of the CCG (although some constitutions include such committees in clause 6.7 or in the Standing Orders in Appendix C).
6.6 Governing Body:
This section deals with the Governing Body and sets out:
6.6.1: Functions: This replicates the statutory functions under the Act but can, and often is, extended, particularly in a “closed” CCG.
6.6.2: Composition: The composition of the Governing Body is set, in part, by Regulations issued earlier this year but the Constitution can provide for additional members of the Governing Body. Most CCGs have taken advantage of this by adding a stated number of GP practice representatives and, in some cases, the number of additional GP practice representatives is significant.
6.6.3: Sub committees: A Governing Body must have Audit and Remuneration Sub Committees but any number of other committees can be added. Generally, in a “closed” CCG greater use is made of sub committees of the Governing Body. Whilst the functions of the Governing Body are set out in clause 6.6.1, the functions and powers of sub committees will be set out in their respective Terms of Reference which may appear in the Constitution but, if not, should be available on request from the Governing Body.
7 Roles and responsibilities of Officers:
Section 7 of the Constitution details the roles and responsibilities of the members of the Governing Body. Of particular relevance to GP Practices will be the roles and responsibilities of Practice Representatives in 7.1.1.
8 Standards of Conduct and Conflicts of Interest:
Clause 8.2 to 8.5 set out the conflict provisions and, in particular, clause 8.2.3 identifies particular conflicts for that CCG and clause 8.4 sets out the procedure to be followed once a conflict has arisen.
C Standing Orders: Appendix C sets out the Standing Orders, which will govern the rules and procedure to be followed for meetings of the CCG, the Governing Body and its committees. This includes calling meetings (3.1), quorum (3.6) and voting (3.7).
D Scheme of Reservation and Delegation: Appendix D determines the division of powers and responsibilities within the CCG. This appears in tabular form and lists, in the rows, the various decisions that will need to be taken by the CCG and sets out, in the columns, the various committees and officers of the CCG (Council of Members, Governing Body, Accountable Officer etc).
Each row has a tick in the relevant column to show who has the delegated responsibility for that particular decision. Accordingly, by studying this, members can determine the extent of the powers delegated to the Governing Body (which will be extensive in a closed CCG) and those reserved to a Council of Members (which will be extensive in an open CCG).
The implications for GP practices
It is important that each GP practice understands how it fits into the overall structure of its CCG, what kind of model has been adopted, the opportunities that member practices will have in participating and how they can participate.
This is all the more important given that the NHS Commissioning Board has announced that practices will be legally bound to the constitution, regardless of whether they have signed it (see ‘CCG constitutions legally binding whether signed or not’, front page of Pulse issue 37, 14 November).
Many member practices are concerned about whether partners participating in a CCG will be personally liability. A CCG is a corporate body and, as such, forms a separate legal entity distinct from its members. Accordingly, the CCG as a distinct corporate body and not its members will be liable for the obligations and liabilities it assumes and incurs.
How to effectively participate in your CCG
As member organisations, GP practices will get out as much as they put in to their CCG. Practices should recognise that a CCG is a democracy and a beauraucracy and accept that they will not agree with every decision made and will have to delegate a considerable amount of decision making power to committees and sub committees, including in particular the governing body.
However, GPs can choose whether they wish to take a more active role by standing for positions on one or more of the committees and should have their voice heard by participating in meetings of the membership. A basic understanding of the structure of the CCG and the powers and responsibilities delegation to the various committees, as set out in the Constitution, will greatly assist that.
Ross Clark is a partner at Hempsons law firm.