As changes introduced by the Government's revolutionary Health and Social Care Act 2012 rapidly take effect, new Clinical Commissioning Groups (CCGs) are being established across the country. In April 2013, the CCGs will take over responsibility for the commissioning of healthcare services from primary care trusts. With only a few months to go before this landmark date, there is a lot to be achieved in a short space of time.
A bit of history
Much to the surprise (and some consternation) of NHS healthcare commissioners and providers, the change of government in 2010 heralded fundamental changes in the NHS organisation. The title of the White Paper for the subsequent legislation - Liberating the NHS - captures the spirit of the reforms: namely a shift of focus from centralised, top-down direction to locally-focussed, clinically-led and patient-centred services.
In practice, this means the abolition of 152 primary care trusts (PCTs), responsible for 80% of NHS annual spending in England, and their replacement by some 212 CCGs. The reforms come into effect at the end of this financial year, with PCTs and strategic health authorities being abolished on 31 March 2013: CCGs and the NHS Commissioning Board (NCB) will be established with effect from 1 April 2013.
How CCGs are organised
These new statutory corporate bodies comprise the GP practices (members of the CCG) in a specific geographical area; typically one or more local authority area(s). The way in which GP practices have come together has not been prescribed, so CCGs vary in size - for example, NHS Cambridgeshire and Peterborough CCG serves a population of 855,000, while NHS Corby CCG serves 68,000 people.
Each CCG will be allocated an amount of money annually to cover all its commissioning and running costs. The figure will be based on the size of the population it serves, so smaller CCGs risk being unviable unless they can work collaboratively to gain the benefits of scale available to larger CCGs. There have already been some 'forced marriages' between nascent CCGs on the grounds of viability, which may be an indicator for the future; especially as mergers of CCGs is explicitly provided for in the legislation.
A CCG must have a governing body, which has statutory responsibility for audit and remuneration functions. All other responsibility for CCG duties and functions - principally around commissioning - lies with the member practices. These can then delegate their authority to the governing body and specific committees as they see fit.
The governing body must have at least six members to include an accountable officer, a finance director, a registered nurse, an acute care specialist and two lay people. The latter are more or less non-executive director roles, one focussed on governance/finance, the other on patient and public engagement. CCGs typically have several GPs on the governing body, who link to the grassroots membership.
The member GP practices are often organised into groups based around a specific locality, but can also be organised on a more fluid basis - for example, to input into the commissioning of specific clinical work streams. Each governing body must have a chair and deputy, and the chair will be the 'face' of the CCG.
Progress towards CCG authorisation
CCGs are currently engaged in finalising their governance structures and appointing staff to governing body and executive roles. The authorisation process - whereby the NCB examines the robustness and readiness of a CCG to take full control of commissioning - has begun and is due to complete in January 2013.
The NCB - itself a fledgling organisation - is running authorisation in four 'waves', looking at how well each CCG addresses six key competencies: clinical focus, patient engagement, planning, governance, collaboration, and leadership. Wave 2 began in September, and the results of the wave 1 authorisation are due to be released during October.
Taking control of commissioning, choosing a support organisation
Currently CCGs are constituted as committees of their respective PCTs. Separate from the authorisation process, they took over operational control of commissioning from PCTs on 1 October 2012. This precedes their establishment as legal entities on 1 April 2013. Consequently, CCGs are not only dealing with authorisation issues but the myriad of tasks around the transition from PCT to CCG control, often with limited resource.
One important aspect of transitional work is the selection of commissioning support units (CSUs), to which CCGs will outsource back office, contract management and business intelligence functions. CSUs are themselves emerging organisations under the aegis of the NCB; there are 23 CSUs working towards being licensed. While CCGs are not compelled to use a CSU, inevitably much of the expertise and relationships they need to get up and running will transfer from PCTs to CSUs.
So, for the near future at least (i.e. to 2016), many of the support services required by CCGs in order to commission will be provided by CSUs.
Working in collaboration
Collaborative working is one of the key competencies for a CCG, and CCGs are looking at how they can leverage their power as commissioners to meet the NHS Quality, Innovation, Prevention and Productivity (QIPP) targets. These apply to all NHS organisations in the drive to achieve value for money and halt ballooning spend.
CCGs are focusing on the big-ticket items - acute care, mental health, community care, commissioning support - and working with those CCGs which buy from the same providers to agree common approaches and strategies. Working collaboratively also allows CCGs to consider commissioning at scale, tackling systemic issues such as excessive A&E admissions, and requiring providers to offer integrated, seamless care pathways.
Another important aspect of collaboration will be CCG joint commissioning with local authorities, together with their input into Health and Wellbeing Boards. These local authority boards are tasked with encouraging integrated health and social care provision, and if appropriately resourced could be an important driver in changing how and what services are commissioned.
Over the years, PCTs have accumulated extensive property portfolios; ranging from social housing 'inherited' from predecessor organisations, to service-specific clinics built under NHS LIFT schemes. When PCTs are abolished, this property will have one of two possible destinations: acquisition by aspirant or existing NHS foundation trusts and NHS trusts on the grounds that it is "service critical clinical infrastructure", or transfer to NHS Property Services Limited, a new company owned by the Department of Health.
Trusts will not be able to acquire a PCT's interests in operational primary care properties (e.g. GP surgeries and dental surgeries) or in LIFT schemes, Private Finance Initiative/Public Private Partnership properties, or any third party developments where the PCT owns the head lease. Changes in commissioning brought in by the reforms - for example, a move from delivering services in acute settings to community settings or patients' homes - could see significant surplus healthcare estate generated in the longer term.