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Where does the clinical bit fit in?

The story so far

Dr Peter Weaving is vice chair of Cumbria CCG, one of the first 35 CCGs set to be authorised next month. When that happens, their hands will be firmly on the purse strings, with a budget of half a billion pounds and a three-year strategic plan drawn up on how to spend it. But with responsibility comes accountability and inevitable paperwork. And every now and again he finds himself asking where the clinical bit of commissioning might have momentarily gone…

My footsteps crunch on the gravel as I walk towards Tom’s house. His wife Kathleen lets me in and shows me upstairs to where he lies, connected up to two syringe drivers, the deep yellow jaundice from his metastatic stomach cancer giving him a deceptive tan.

Tom has had a good couple of years from his gastric surgery, but this is the end-game and we all know it. He’s comfortable and peaceful, cared for by his family and supported by community nurses. Kathleen lets me out into the cooling autumn afternoon air.

I wander thoughtfully back to my car looking up at the house next-door-but-one as I go, and thinking back nearly 20 years. Mum and midwives did the labouring that day, and I provided token medical support. A healthy baby girl was delivered and dad walked down the hill to fetch brother and sister from school to meet their new sibling.

Now, as I take off my rose-tinted spectacles and look back over the last five years, I’ve been involved in the commissioning of all these services – maternity to palliative care and public health to cancer surgery.

So what does the future hold for our commissioning clinicians in their about-to-be-authorised CCGs? A very big clue comes in the authorisation process itself, six domains with 119 standards described as radio buttons and coloured either red or green.

The voluminous submission of documents by aspirant CCGs to meet these standards is assessed, quantified and summarised in a ‘desktop summary report’ that is returned to each CCG. To date, most CCGs score between 65-85% green buttons.

The next stage of the process is a site visit, where the CCG is visited by a panel of senior individuals chaired, for example, by a PCT cluster chief executive whose remit is to follow pre-determined key lines of enquiry (KLOEs) to probe deficiencies in the desktop summary report.

The failure to close off KLOEs determines the number and scope of restrictions to be placed on the CCG when it becomes operational. The site visit is the first contact between the CCG and the NHS Commissioning Board, and is described as heralding the new adult-to-adult relationship between the two. It provides the opportunity for CCGs to respond to such questions as: ‘Have you discussed your plans for supporting research with other CCGs and with the proposed AHSN?’ (Whatever that is.)

My concern with this very proscriptive – although described as developmental and ‘utilising a constructive appreciative enquiry approach’ – assessment is that I think it’s missing the point about what a clinician brings to a clinical commissioning group – a balanced understanding of the requirement of clinical services to meet the needs and expectations of patients.