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The CCG details have only just begun

Why do we need a health act? That was the question I heard a prominent GP commissioner ask his colleagues 18 months’ ago during the Health and Social Care Act ‘pause’.

And he had a good point. The legislation brought in under PMS allowed GPs to be given real budgets – Bexley GPs had real prescribing budgets as far back as 2009.

Politicians like to change things through legislation and the health act with its abolition of SHAs and PCTs, certainly served a purpose of putting clinical commissioning at the heart of the future of the NHS. It gave PBC the ‘oomph’ other ministers could only talk of, as most PCTs would simply not give up control to GPs.

But it was also at that point that I realised the devil of this act would be in the detail; the competition regulations, tariff-setting, budget allocations to CCGs and the dynamic of the relationship between CCGs and the NHS Commissioning Board. Commissioning Support Units hadn’t even been articulated yet.

As I prepare to leave Practical Commissioning for pastures new and look around our website content, that detail is only just starting to reveal itself.

The competition regulations, despite the reassurances from ministers, are still being subject to claims that they will require CCGs to tender all service or to use AQP.

The Lewisham experience reflects the findings of an internal marketing survey of 40 CCG senior members we recently did at Practical Commissioning where we asked what their CCG’sbiggest headache was. The overwhelming answer was the financial fragility of their local hospital. Unless CCGs are given the real opportunity to work with their local hospital to sort out their financial problems and come up with a long-term solution – which clearly didn’t happen in Lewisham - I fear many CCG members will walk away from commissioning.

My interview with Bob Ricketts draws out some of the challenges ahead for CCGs on local price-setting for any qualified provider and gives some insight into how much is involved in pricing.

But against these articles on the health act details, the case-studies of what CCGs can do, keep on coming. I particularly like our recent feature on how the health and wellbeing board in Middlesbrough is shaping up.

It reflects what CCGs know - the challenges ahead are bigger than they are.

GPs know they can’t meet the local health needs through health care alone. And so we are already starting to see case studies of CCGs spending cash on blankets and fuel for patients. But this joint working with local authorities is a double-edged sword – for how long will CCGs tolerate examples of public health budgets being spent on road gritters and leisure centres?

CCGs can’t destabilise the local health provider and so are coming to a crossroads of deciding on competition or integration.

And the beauty of the provider ‘side’ of healthcare is that this is where patients truly engage in a way they will probably never do with commissioning.

And integration, creating a unique provider model that no other provider could come up with, could be the vital safeguard to competition lawyers.

So my parting thought is that CCGs really need to be ‘on’ the detail in the next year.

No small challenge giving what they’ve got to sort out in their own back yards.

But they need to satisfy themselves the competition laws will not require them to tender everything, make the NHS their preferred provider if that’s what they think is best for their local population, challenge Monitor if it sets prices too low, expose local contracts with unstable prices and if they find themselves in a situation like Lewisham, consider their positions.

As Voltaire said: ‘judge a man by his questions’ : Why do we need a health act?

 Sue McNulty is editor of Practical Commissioning.

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