The Myles Report: The Dawn of The Clinical Commissioning Groups And The NHS Reforms

YT columnist, Myles Cook specialises on issues surrounding health.

Myles has taken a considerable amount of time to look at the new clinical commissioning groups.

This is a more academic submission, than a blog entry.

This is Part One….The other parts will be published over the next week.

April 1st 2013 will be a date that goes down in history, for good or for bad, as the day the National Health Service changed as part of the Coalition’s top-down reorganisation of our most precious public service. Gone will be the old Primary Care Trusts (PCTs) who commissioned the health services for their particular areas and in will come the new health commissioners – the Clinical Commissioning Groups (CCGs). Whether this is a good thing is a matter for people in the present to argue and debate and for future historians to judge based on hindsight.

However, to debate an issue, one must have the facts on the subject and the opinions of others to form one’s own opinion and to take one’s own position so I present to you the facts and the opinions surrounding the issue of CCGs.

The Facts Around Clinical Commissioning Groups

Primary Care Trusts have been viewed as bureaucratic behemoths with layers of unnecessary management.

The reforms of health and social care were outlined in the Health and Social Care Bill. The Bill received Royal Assent and became the Health and Social Care Act 2012 on 27 March 2012. (http://en.wikipedia.org/wiki/Health_and_Social_Care_Act_2012)

As part of the reforms of the NHS brought into being by former Health Secretary Andrew Lansley, groups of General Practitioners (GPs) were formed. These groups would become known variously as GP Consortia, GP Commissioning Groups and, ultimately, Clinical Commissioning Groups.

GP Pathfinder Groups were set up as the first CCGs. These Pathfinder groups were to “operate in shadow form alongside the PCTs”.

By March 2011, 177 pathfinder CCGs had already been formed.

Effectively from April 1st, CCGs (and by implication, GPs) are being handed the purse strings to a large proportion – £65 billion – of the £95 billion NHS commissioning budget.

Since the introduction of the Health and Social Care Act, the CCGs have been shadowing the old PCTs with a view to taking over the commissioning of health services in their local areas.

Services that CCGs will be responsible for commissioning or buying will include: elective hospital care, rehabilitation care, urgent and emergency care, most community health services and mental health and learning disability services.

CCGs will work with patients and healthcare professionals and in partnership with local communities and local authorities.

CCG governing bodies must have at least one registered nurse and a doctor who is a secondary care specialist.

CCG boundaries will not normally cross local authority boundaries.

CCGs will be responsible for arranging emergency and urgent care services within their boundaries, and for commissioning services for any unregistered patients who live in their area.

All GP practices will have to belong to a CCG.

The newly formed NHS Commissioning Board (NHSCB) has the duty to make sure that all CCGs have “the capacity and capability to commission services successfully and to meet their financial responsibilities”.

The NHSCB was created in shadow form in June 2011 and became fully operational from April 2012.

The NHSCB will still be directly responsible for commissioning the following services: Pharmacy services, General Practice, Dentistry services and Specialist services (specialised services that are required by a limited number of people).

Local authorities will have to set up Health and Wellbeing Boards (HWBs) to “ensure that Clinical Commissioning Groups are meeting the needs of local people”.

HWBs will have members from CCGs, Directors of public health, Children’s services, Adult Social Services, Elected councillors and local HealthWatch branches (representing the views of patients, carers and local communities).

HWBs were in place in shadow form April 2012 and were be operational from April 2013.

(Quotes and reference material from http://www.phorcast.org.uk/page.php?page_id=259)

In a press release on the 14th March 2013, the NHS Commissioning Board made the following announcement: “In total, 43 of the 211 CCGs have been fully authorised, meaning they met all 119 criteria for authorisation. A further 168 CCGs have been authorised with conditions, meaning they have some additional work to do before they fully meet the criteria. A total of 15 CCGs have also been issued with legal directions, meaning the NHS Commissioning Board, and in some cases neighbouring CCGs, will provide more formal development support, underpinned by legally-binding instructions. The effect of a direction is to either direct how the CCG must work with another CCG or the NHS Commissioning Board to exercise functions.” (http://www.commissioningboard.nhs.uk/blog/2013/03/14/wave4-auth/)

Thurrock CCG was one of the 15 groups who had been issued with legal directions.

At a meeting of Thurrock Council’s Health & Well-Being Overview and Scrutiny Committee on 4th December 2012, Mandy Ansell, Chief Operating Officer for Thurrock CCG, said that there would be no sanctions against GPs as healthcare providers but they would be “forced” into joining eventually, when questioned about GPs who were reluctant to join the group.

CCGs: From The Horse’s Mouth

Architect of the Health and Social Care Bill, Andrew Lansley, had a vision for the new NHS. Below are some quotes of what that vision was:

“The clinical commissioning groups will be statutory bodies, and will therefore not be able to delegate the responsibility for such commissioning to any other organisation, including a private sector organisation.” (Hansard source (Citation: HC Deb, 14 June 2011, c657))

“…we are shifting the ownership of commissioning and the responsibility for the design and delivery of services from what is essentially a distant managerial organisation into one that is locked into the clinical decision making of doctors and nurses across the service.” (Hansard source (Citation: HC Deb, 14 June 2011, c653))

“…local general practices—together in a commissioning consortium—and their other health care professionals, meeting with the health and wellbeing board in the local authority, will be able to bring democratic accountability in order to ensure that they have in her town and surrounding area the necessary services, based on a strategic assessment of need in their area.” (Hansard source (Citation: HC Deb, 8 March 2011, c770))

“Consortia will be able to reinvest any savings they make from their commissioning budgets for patients into improving patient care and health outcomes for patients for whom they are responsible. We have also proposed that consortia should receive a quality premium based on the outcomes achieved for patients, similar at a consortium level to the quality and outcomes framework for individual practices. That will incentivise the consortium as a whole to deliver improving outcomes for patients.” (Hansard source (Citation: HC Deb, 8 March 2011, c759))

Following the ‘pause, reflect and improve’ exercise, Mr Lansley gave the following statement in response to the NHS Future Forum’s report: “In his report, Professor Field set out clearly that the NHS must change if it is to respond to challenges and realise the opportunities of more preventive, personalised, integrated and effective care. The forum said that the principles of NHS modernisation were supported: to put patients at the heart of care, to focus on quality and outcomes for patients, and to give clinicians a central role in commissioning health services.

“…One of the most vital areas of modernisation to get right is the commissioning of local services. For commissioning to be effective, the process of designing services must draw on a wide range of people, including clinicians, patients and patient groups, carers and charities. We will amend the Bill so that the governing body of every clinical commissioning group will have at least two lay members, one focusing on public and patient involvement and the other overseeing key elements of governance, such as audit, remuneration and managing conflicts of interest. Although we should not centrally prescribe the make-up of the governing body, it will have to include at least one registered nurse and one secondary care specialist doctor. To avoid any potential conflict of interest, neither should be employed by a local health provider. The governing bodies will meet in public and publish their minutes. The clinical commissioning groups will also have to publish details of all their contracts with health service providers.

“…Building on that multi-professional involvement, clinical commissioning groups will have a duty to promote integrated health and social care with regard to the needs of their users. To encourage greater integration between social care and public health, the boundaries of clinical commissioning groups should not normally cross those of local authorities. If they do, clinical commissioning groups will need to demonstrate to the NHS commissioning board a clear rationale for doing so in terms of benefit to patients.” (Hansard source (Citation: HC Deb, 14 June 2011, c644))

He continued: “We will further clarify the duties on the NHS commissioning board and clinical commissioning groups to involve patients, carers and the public. Commissioning groups will have to consult the public on their annual commissioning plans and involve them in any changes that would affect patient services.

“…However, individual clinical commissioning groups will not be authorised to take over any part of the commissioning budget until they are ready to do so. Individual GPs need not take managerial responsibility in a commissioning group if they do not want to, and April 2013 will not be a “drop dead” date for the new commissioners. Where a clinical commissioning group is not able to take on some or all aspects of commissioning, the local arms of the NHS commissioning board will commission on its behalf. Those groups that are keen to press on will not in any way be prevented from becoming fully authorised as soon as they are ready.” (Hansard source (Citation: HC Deb, 14 June 2011, c645))

“It is precisely that process of engaging clinicians, who will come together to design services around the needs of patients in a way that delivers not just improving productivity, but improving quality of services for patients, that is at the heart of the shift from primary care trusts and strategic health authorities.

Let’s face it: the Labour party spent a decade presiding over declining productivity, while the costs of bureaucracy and management in the NHS doubled. We will empower people in the NHS to deliver improving services and reduce bureaucracy.” [emphasis added] (Hansard source (Citation: HC Deb, 14 June 2011, c649))

“…sustaining the structure that we inherited from the Labour party, with all the strategic health authorities and all the primary care trusts—this vast bureaucracy— could never have happened. We had to take out administration costs in the service…” (Hansard source (Citation: HC Deb, 14 June 2011, c650))

“It is essential to move to a world where we reduce administration costs, relieve bureaucracy in the service and free those providing services by offering them the resources to deliver improving care without the burden of bureaucracy, cost and waste inflicted by a Labour Government in the past.” [emphasis added] (Hansard source (Citation: HC Deb, 14 June 2011, c652))

“It is because I believe in the NHS and the people who work in the NHS that I think it right to listen to and engage with those people, and to give them much greater control of the service that they provide for patients.” [emphasis added] (Hansard source (Citation: HC Deb, 14 June 2011, c655))

“Many GPs across the country understand that clinically led commissioning is the right thing to do, but they do not personally want to be involved in that process. There are, however, leaders who do, and leaders across the country have already come forward through pathfinder consortia and will be a basis on which we can create much greater clinical leadership across the service.” [emphasis added] (Hansard source (Citation: HC Deb, 14 June 2011, c658))

“We are going to transfer resources from bureaucracy, management and administration into front-line care. Through clinical commissioning groups we are going to empower staff in the NHS, and abolishing two tiers of management…” (Hansard source (Citation: HC Deb, 14 June 2011, c659))

“General practice—not just general practitioners but general practice—has a central role for patients because there is a long-term relationship with patients and an understanding of the whole population and the health of a whole area. However, GPs recognise that in order to get the right services for patients, they have to design services alongside the range of professionals whose job it is to deliver them.” (Hansard source (Citation: HC Deb, 14 June 2011, c660))

In response to Ronnie Campbell’s assertion that the Health and Social Care Bill was “a slow-privatisation-of-the-NHS Bill”: “This Bill and our proposals were never to support privatisation; they are not to support privatisation and they will not be to support privatisation.” (Hansard source (Citation: HC Deb, 14 June 2011, c660))