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Change at the coalface

Last year with the ink still wet on the health white paper, we asked commissioning leads from nine GP consortia for a progress report on their activity. A year on, we spoke to them* about their current preoccupations in light of the changes to the health bill

1. Are you sticking to the original 2013 deadline?

The change: Originally, the Government said all GPs must be in a clinical commissioning group (CCG) by April 2013. In its response to the Future Forum listening exercise in June, the Government said CCGs ‘will not be authorised to take on any part of the commissioning budget until they are ready and willing to do so – where a group is not yet ready, the NHS Commissioning Board will commission on its behalf.'

JR: We should be ready by April 2013. But the rumour is that CCGs will have to have a minimum of 250,000 patients or even closer to 500,000, and we're nowhere near that.

In terms of local responsiveness, it's going in the wrong direction and it blows all the work we've done out of the water. We're now getting married to the consortium next door (C4) and possibly another.

We've worked out heads of terms with C4, and together we're still not up to 250,000 patients. It's annoying because we've done a huge amount of work – including sorting out our financial risk-sharing scheme – which will have to be worked out again.

CH: I think we are ploughing on with the original timetable. Budgets are being aligned in shadow form to localities which may engender some ownership down to practice level.

GK: The six CCGs locally have all put 2013 in their delivery plans that will be signed off very shortly.

But we've done that, subject to a lot of caveats. For us, it's subject to getting the right support in place, data, support from secondary care and so on.

That to some extent depends on the question of whether we'll have to federate and how that will affect things – as well as the question of whether PCT clusters will remain as outposts of the NHS Commissioning Board. Will they be providing the back-office functions?

BT: We will stick to the deadline for all sorts of reasons. We think that if we can be at the front of the queue, the coalition Government won't want us to fail.

Also, PCT staff still don't know where they'll be, so we want to sort out as much as we can as quickly as possible. We were very good at getting going. Now we don't want to lose the momentum.

PI: The view in Wandsworth is just to keep going at the same pace and our pace is set to meet the April 2013 deadline. If we keep up the same momentum, we'll make it.

MD: We didn't feel we wanted to stop just because of the pause. We're very much going for that date and are currently looking at the ins and outs of authorisation.

With the PCT slimming down, progress does suffer though. Everyone is so constrained they have less project management time for us.

TB: We're still planning for April 2013 – in fact, we're hoping to have the budget delegated to us in August this year. We won't be the accountable organisation for it yet. This is an aspiration across the whole of south-west London, but still has to be approved.

One practice locally has elected not to join a consortium until forcibly allocated to one. But that doesn't really affect us.

MS: We are going for April 2013. Our progress has not been slowed by the listening pause.

JH: The deadline being lifted makes no difference to us as we want to be authorised as soon as we can. My understanding is that the NHS Commissioning Board will be empowered to authorise from October 2012. So there will be a six-month window running up to April 2013.

It's not clear yet when you can pass through the gate, but we want to be ready as soon as we can because by then, under the timetable we've agreed with the PCT, we will have taken over all the functions. It's a good thing to be ahead of the curve – we can plan and organise staffing sooner.

2. Do you feel your power has been diluted by changes announced to governing bodies and the introduction of clinical senates?

The change: The Government response to the Future Forum report says ‘at least one registered nurse and secondary care specialist doctor' must be appointed to CCGs' governing bodies and they ‘must have no conflict of interest in relation to the CCG's responsibilities'. It also announces clinical senates that will ‘make sure that a range of professionals play an integral part in the clinical commissioning of patient care'.

JR: The broader clinical senate will plan commissioning for large areas. I can see the value in planning area-wide, but we'll need to keep a reality check on what they are doing because the buck stops with us.

As for getting consultants from out of area (for the CCGs), we're surrounded by sea! Where are they going to come from? It's probably just tokenism, but what are they actually going to do when they get here after a three-hour drive?

CH: Even if it does not dilute the power, these changes create a feeling of lost autonomy and hence the loss of personal ownership of the role to drive progress. I'm not sure where our nurse or consultant will emerge from or how one consultant from out of area can give a proper perspective to emerging plans.

GK: The clinical senates will be a good thing, but it is another layer – it could hinder progress. It's basically a PEC, and personally I was hoping we might be able to bring about change quicker than we could under a PEC.

BT: We're not entirely sure where our clinical senate will fit in. We've also got our PCT clustering to contend with – ours is one of the biggest, so now it looks as if we'll have a local cluster office to deal with too.

The approach I'm taking with all of this is just to carry on as I'm doing for now. I worry, of course, that we could all be rendered toothless by tokenism and end up with less freedom and more responsibility. As for getting a consultant from outside the area – I'm sure there will be ways and means, but as for what they'll do, I haven't got a clue. I just think (health secretary Andrew) Lansley is playing a political game and thinks he can keep critics quiet by ticking certain boxes.

PI: I have absolutely no idea what clinical senates are for. I really don't understand this. My personal view is that we need to get away from the word ‘clinical'. We need to be thinking broadly. And this just seems to be be another tier, another level that we don't really need.

MD: We already have what we call a joint clinical forum – not looking at contracting issues, but looking at what we do more widely. We're thinking the clinical senate could be a constructive thing. I don't know if it will equate to a PEC or not yet. There is a slight concern over how many layers we'll have to go through to get our plans actioned.

We've already got a practice nurse on our board, so the focus on nursing issues is already there. We may have to include a hospital nurse under the new plans.

TB: We're not sure how the new clinical senates will work. Hopefully, it won't mean another tier of meetings. It's confusing because there's also a pan-London clinical senate set up to deal with things like cancer services, dialysis and so on.

MS: We'll have one clinical senate across the three local consortia and that will be the place where commissioning is co-ordinated.

JH: The view so far is that there isn't enough detail yet to know what powers the senate will have and how it will fit in. Our position would be that we're keen to work with other bodies.

3. How will any qualified provider (AQP) work locally?

The change: The Government response to the Future Forum report says: ‘We maintain our commitment to extending patients' choice to AQP, but we will do this in a much more phased way. Choice of AQP will be limited to services covered by national or local tariff pricing, to ensure competition is based on quality.'

Last month, further guidance was issued by the Department of Health saying by October 2011, PCT clusters must identify three or more community or mental health services for AQP that they will implement in 2012.

CH: Mental health needs looking at as Improving Access to Psychological Therapies is not performing as well as it needs to. The mental health budget – at 10% of overall PCT spend – does seem intuitively high. AQP can work well if commissioners choose the target areas well.

GK: We think it should be a useful tool. There's a problem in that there are so many people to provide now. You've got LLPs, external providers, foundation trusts, the private sector and individual providers such as chiropodists – a lot of people vying for business.

BT: I think AQP has been kept in the mix because of the choice mantra. I don't have any political or philosophical axe to grind over this. We'll just get on with it and use whatever tools are available to us.

PI: The opportunity created by allowing AQP is not a bad one. What is slightly worrying is that for a very mixed service model, pathways can become confused. However, in general practice we often don't think about provision enough and AQP is a good stimulus to do that.

MD: We'll have to wait and see how this works out. Our focus has been elsewhere.

As we've been advised to do on most of the details, we'll wait and watch.

TB: I'm very pleased that the option of AQP hasn't been taken away, because otherwise we'd have no levers at all. People in some parts of the country are dominated by one acute provider and can't do anything about it. My view is that choice is not a bad thing.

MS: AQP is a very good card to keep up our sleeve. We're very supportive of our foundation trust. But if they can't provide up to the specification we want, we'll go to other providers.

There are plenty of these locally – for example, the GP co-op organisations that were set up in the 1990s that are looking at meeting gaps. It keeps the trust on the front foot. I really can't see that there's a lot in this for independent providers, though. There's no real money to be made. I can't see Virgin being interested in a 5% margin. But we will get plenty of GPs and social enterprises interested.

JH: I don't think this will affect things hugely.

4. How will health and wellbeing boards fit into the local picture?

The change: The Government's response says: ‘Health and wellbeing boards will have a stronger role in promoting joint commissioning and integrated provision.' The health and wellbeing boards will also have a ‘stronger role' in leading on local public involvement and there will be a ‘stronger expectation' for NHS commissioning plans to follow the local health and wellbeing strategy. They will also have the right to refer plans back to the CCGs or the NHS Commissioning Board for further consideration – although not a veto.

JR: This is not exactly clear yet. It appears there might not be able to be any CCG decisions without their assent – so who actually holds the ring? Where's that going to leave you as commissioners? If common sense prevails, it will just be a rubber-stamping exercise.

The thing is, the board won't be responsible for finance and that makes it a bit like going into Tesco and trying to do your shopping when someone else has got the purse. The original principle was a good one, as far as I'm concerned. It makes sense to have your wallet in your pocket when you go shopping.

CH: I don't think we know. Are we sure the role and composition has now been established? There is such a state of flux at present that one has emerging model fatigue.

GK: We've been working quite closely with our health and wellbeing board. The changes are going to make this, let's say, more constructive. We'll have to work that much more closely or it will create more red tape if we're not careful.

So far, I've found them an asset, but I just have a feeling there could be more politics involved from now on. Our understanding at the moment is that quality premiums will be linked to the health and wellbeing agenda, but we're waiting to hear more.

BT: We don't really know how this is going to work out. We're just in the process of forming this and working out who the members will be. But I still haven't got my head around how we'll work together.

PI: We've already formed our health and wellbeing board. It has been meeting once every eight weeks. In my idealistic, altruistic view, this should be the central decision-making panel for the whole thing.

We should only have health and wellbeing boards, then there would be no separation between health and social care. We do need to understand each others' drivers and barriers – on the health side we have our budgets and pathways, on the local authority side there are political considerations. But once that's all understood, it can be put to one side.

MD: We've already got excellent relationships with our local authority. The director of public health has been instrumental in pulling it all together, and the local authority has a role on our board too.

We'll have managerial and clinical leadership of it, but will need to think about how it tackles issues like integrated care and intermediate care services. We'll also look at the scrutiny role. Whether the quality premiums will be linked to the health and wellbeing agenda isn't clear yet.

TB: We've got a well-established health and wellbeing board – at the moment, in an advisory role. We've had the first two meetings and there's a ‘meet the board' session next week. They are looking at the new functions. We'll need to make sure that actions are followed through, but it won't have any effect on what we do. Our work is already very influenced by public health concerns.

MS: We've got three levels of health and wellbeing board – a Fleetwood-focused committee, a health improvement committee at district council level that is now being rebadged as a health and wellbeing board and one sitting at Lancashire County Council level. How we'll be inputting into that I don't know.

JH: From a Somerset perspective, we're very optimistic about the health and wellbeing board architecture. The changes to the bill appear to give it a stronger role.

We aim to have a shadow board up and running, probably in the autumn. We've already got joint arrangements with local authorities so we'll build on what's there already.

What´s on your information wishlist?

JR: We just need some clarity - on size, on senates and their relationship to the CCG board and on GP buy-in. Enthusiasts like me have been keen to be fleet of foot. We thought the dead hand of bureaucracy was going to be lifted. Now we´re not so sure. Those who were tepid before are even more tepid. People are using terms like ‘change fatigue'.

CH: Still unsure if we can liberate enough money to cost effectively have doctors meeting about the truly clinical aspects of system change.

GK: Our key need is for data. We need information that´s been validated so we can plan. Secondly we need more information about existing contracts so we know whether to negotiate with the current providers or look elsewhere. Without that we can´t prepare sensible business plans.

BT: We need clarity over governance. You´ve got the cluster, the senate, the health and wellbeing board and the commissioning board and we´re just not sure about how it's all going to fit together. Presently, we are in limbo. When the stuff hits the fan, who´s going be standing in front of it?  In the meantime, I see my role as keeping practices on board and enthusiastic.

PI: Data and information is key. It´s one of the things that has let us down for a long time. In the process of commissioning a new service it´s risky and dangerous if you don´t fully understand what you are doing and if you´re biting down hard on a contract. It´s very difficult if your data is not accurate.

The other thing we need is really good systems of communication. Email is failing us. It´s overrun, full and unprioritised. We need to start boxing clever with some variations on how we communicate and how we store information. We need to look at some corporate technologies - some companies are using instant messaging systems like MSN and we could also do with developing more remote meetings.

MD: This is where the rubber hits the road on commissioning. We´ve got all our information on budgets and prescribing and so on in one place at the moment but we´ll have to wait and see if we afford to run it at a local level. If not we may need to think about commissioning it at national level using an organisation such as Dr Foster.

TB: It´s very unsettling for people at the moment and it´s amazing that we have high quality people who want to stay in the health service when there is such a lack of clarity. It´s very difficult to develop a structure that we hope will be fit for purpose when we don´t have the full picture of what we´re trying to do.

The time input is huge - not just for the CCG, but also at (PCT) cluster level to get things like the delivery of big services joined up. This is potentially explosive because it means the potential closure of A&Es and maternity units.

MS: We´d like to know what our management allowance is going to be. If it´s 20 quid, it´s 20 quid. And we also need to know what the authorisation process is going to be. How do we get to being a statutory body by April 2013? We need to know what hoops to jump through.

JH: Two things: We need the management allowance figure so we can get down to detailed planning. We also need the forthcoming guidance on the authorisation process. This is going to be a big piece of work and we want to start gearing ourselves up for authorisation.

What else are you talking about at the moment?

JR: Conflict of interest. As providers, we´ve put a conflict of interest statement in our draft terms with C4. We´re hoping that will be enough. There´s a meeting soon at the Department of Health hopefully to nail this. I think the DH has realised there are a lot of GPs out there who provide care so this idea that you somehow have a dirty habit or an incurable disease will go away.

CH: Telehealth/medicine/care is likely to have a large impact on health and social care.

GK: The biggest pressure we´re under is the cuts in funding - the proposed ?20billion. The Department of Health is telling us we shouldn´t have to start off in debt but PCTs are saying if you don´t make these savings you´ll start with a negative baseline. And because the rules keep changing we´re constantly revising our delivery plans. Things have changed several times in the last three or four weeks, which has meant many more meetings. You´re left thinking: isn´t that what PCTs do?

BT: We´re going to have an away day with the other local hubs (CCGs) to work out whether we have separate boards or an overarching board. Between us we´d have about half a million patients. There are all sorts of rumours going around about what size we´ll have to be.

PI: We´ve just formed a clinical cabinet and we´re advertising for an overall clinical lead who would ideally be a salaried GP - the commissioning part would be a dedicated post. They´ll essentially be an employee of the CCG. The idea is that all the rest of us are partners - effectively running small businesses in the form of our practices - so it's difficult to dedicate ourselves to commissioning. But a salaried doctor won´t have those pressures. Also, if they´re salaried, albeit through a local practice, under challenge, say from an outside provider they won´t be subject to the same allegations of bias if provision goes to a local colleague.

MD: We´re very much taken up with process at the moment but are trying really just to keep the show on the road. We´ve become a second wave pathfinder and done a lot of work over the past year or so on things like urgent care, prescribing and variation in healthcare. We´ll carry on laying the foundations.

TB: Financially we are under huge pressure which is clearly expressed by the delay in signing off contracts in London and the Foundation Trust applications that have gone on the back burner. It´s going to make decision making very difficult.

 Our three priorities are to establish our commissioning work programme so we can take up responsibilities from the PCT. Secondly to establish a programme of support for the nine federations (CCGs) in Somerset. And thirdly to start to prepare for authorisation.