How clinical commissioning groups will work

GPonline.com explains how commissioning will work in light of changes to the Health Bill.

Since the initial publication of its Health Bill in January this year, the government has been forced to amend its plans for reforming the NHS.

While a number of proposals have been watered down, the idea that clinicians, and GPs in particular, should be responsible for commissioning patient care, remains at the heart of the Bill. However, the revised Bill will make a number of changes that will have a direct impact on how GP consortia – or clinical commissioning groups, as they must now be known – will operate.

Below is our guide to everything we currently know about clinical commissioning groups and how they will work.

Click on the image below to access our interactive timeline of the NHS reforms

Size and structure 
As was previously the case with GP consortia, clinical commissioning groups (CCGs) will be free to merge or expand. Each CCG will need to be approved by the NHS Commissioning Board. There will be no minimum or maximum size, but the NHS Commissioning Board must be satisfied a group’s population is appropriate.

So far 257 clinical commissioning groups have been granted pathfinder status. However, it has been suggested that some groups are currently too small and may need to merge.

Every GP practice will be part of a commissioning group and legislation will ensure practices cannot operate if they do not join a group. Practices that have not done so by 2012 will be placed into one by the NHS Commissioning Board.

Following criticism in the NHS Future Forum report, the government has now decided that CCGs should not cross local authority boundaries. Any group that wishes to do so will have to justify this by demonstrating a clear benefit to patients.

CCGs will now be expected to take a name that uses the NHS brand and has a clear link to their locality. The groups will be able to work in partnership when commissioning services, but they will not be allowed to delegate their responsibility for commissioning to private companies or contractors.

Governing body
Every CCG must have a governing body or board that will have decision-making powers. This must include at least two lay members – one with a lead role in championing patient and public involvement and the other with a lead role in overseeing key elements of governance. One of the lay members will either be the chair or the deputy chair of the governing body.

The governing body must also include at least one registered nurse and one doctor from secondary care, although in order for there to be no conflict of interest these individuals must not be employed by a local provider.

Governing bodies will be required to meet in public and publish the minutes of their meetings.

NHS Commissioning Board
The NHS Commissioning Board will hold CCGs to account on measures in a Commissioning Outcomes Framework, based on NICE advice. The board will intervene if ‘there is evidence that commissioning groups are failing or are likely to fail to fulfil their functions’. It will also issue guidance on financial risk management.

The revisions to the Health Bill will also set out a series of new bodies that will have some say in CCGs’ commissioning decisions. How much say or influence these groups will have remains to be seen.

Clinical senates
England will have around 15 regional clinical senates that will bring together doctors, nurses and other professionals, including public health and social care experts. They will provide advice on how to make patient care fit together, which CCGs will be expected to follow.

The senates will have a formal role in authorising CCGs and will advise the NHS Commissioning Board on the groups' commissioning plans and any major service change in the region.

Clinical networks
Clinical networks will bring together experts in specific clinical specialties, including patients and carers, and will have ‘a stronger role in commissioning’. The government is not clear on what this means, but in practice these networks are likely to help CCGs decide how best to reconfigure services in a specific specialty and help them establish their commissioning priorities.

Both the clinical networks and clinical senates will be ‘hosted’ by the NHS Commissioning Board, rather than being new organisations.

Health and wellbeing boards
Health and wellbeing boards are structures that will sit between local authorities and commissioning groups. They will also have a 'formal role in authorising' CCGs to become statutory organisations. Although CCGs will be represented on health and wellbeing boards, local authorities will control their make-up, and ‘will be free to insist upon having a majority of elected councillors’.

Commissioning groups will be expected to involve health and wellbeing boards throughout the process of developing commissioning plans. Under statutory guidance, CCGs will be required to develop plans in line with the health and wellbeing strategy and health and wellbeing boards will have the right to refer commissioning plans back to the NHS Commissioning Board if they feel they do not meet this requirement.

HealthWatch
HealthWatch England will be set up as a new patient representative organisation to provide patients and the public with a voice at national level. Local HealthWatch groups, which will replace current patient involvement groups, will ‘scrutinise’ local commissioning. 

Monitor
Following the listening exercise, Monitor’s role has been changed and its core duty will now be to protect and promote patients’ interest. It will be required to support the delivery of integrated services and ensure that competition is fair and operating in the interests of patients.

Monitor says it will ‘tackle specific abuses and restrictions that act against patients' interests, to ensure a level playing field between providers.’ Monitor will investigate any complaints about CCGs acting anti-competitively, but it will not performance manage commissioning groups.

Click here for our diagram of the new NHS structure.

Transition to new system
PCTs are now involving clinical commissioning groups in NHS contracting, with a view to transferring functions by April 2013, where possible. PCTs have merged into clusters to cut costs and consolidate falling staff numbers and functions.

In April 2013 PCTs and SHAs will be abolished and the NHS Commissioning Board will take on its full responsibilities (it will be established in October 2012 to authorise commissioning groups).

Clinical commissioning groups that are ready and willing by April 2013 could be authorised to take on full budgetary responsibility. However, some will only be authorised to take on part of the budget and others will only be established in shadow form.

Where a group is established in shadow form the NHS Commissioning Board will commission on the CCG’s behalf via local arrangements (likely to be the local PCT cluster) until it is ready to take on full commissioning responsibility.

Funding and PCT debt
CCGs will be responsible for debts PCTs accrue in their final two years - 2011/12 and 2012/13. Commissioning groups and PCTs are expected to work closely in this period to ‘reduce the risk’ of deficit as PCTs are abolished. CCGs will not be directly responsible for deficits accrued in 2010/11 or earlier.

The government plans to pay CCGs a ‘quality premium’ to reward successful commissioning, however this controversial premium has been removed from the Health Bill after accusations that it could create perverse incentives.

The government plans to set out in detail how this payment will work, with tough new rules on how CCGs can earn the payment, and what they can use it to pay for. However, the BMA is still highly critical of the plans.

It is currently unclear where the money for the premium will come from and whether it will be top-sliced from CCGs’ commissioning budgets or, as some fear, from GP practice funding, or if it will new money.

From April this year, consortia received £2 per head to fund GP involvement, on top of existing practice-based commissioning funds. By 2014/15, commissioning groups will receive £25 to £35 per patient to cover running costs.

But the DoH has not confirmed how much they will receive in 2013/14, the first year in which they are fully operational. The GPC has said that commissioning groups may be short of cash once infrastructure costs are deducted.

Work on a formula to allocate consortia budgets based on member practices' lists may take until 2013 to complete.

The NHS Commissioning Board will have powers to establish and maintain a risk pool with CCGs to help manage expensive episodes of care.

Timeline

October 2011

  • NHS Commissioning Board established in shadow form as a special health authority

October 2012

  • NHS Commissioning Board established as an independent statutory body, but initially only carries out limited functions, in particular authorising clinical groups.
  • HealthWatch England and local HealthWatch established.

1 April 2013

  • SHAs and PCTs abolished and NHS Commissioning Board takes on full functions.
  • Clinical commissioning groups established, but groups are only authorised to take on full responsibilities when they are ready.

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