Analysis: Fears growing over the freedom of clinical commissioning groups (CCGs)

With the authorisation process for clinical commissioning groups (CCGs) due to start this summer, GP leaders remain concerned that the groups will be denied genuine freedom to make their own decisions.

Dame Barbara Hakin: most commissioning support is NCB-hosted (Photograph: P Hill)
Dame Barbara Hakin: most commissioning support is NCB-hosted (Photograph: P Hill)

Details are starting to emerge of how the reformed NHS will look, as the DH reveals how the NHS Commissioning Board (NCB) and its outposts will be structured (see box, below).

But much of the detail on how the NHS will really work is still to be determined, and will become clear only once secondary legislation appears and consultations about parts of the reforms are completed over the next year.

  • NCB with nine national directorates: chief officer, medical director, chief nursing officer, finance, commissioning, patient involvement, improvement, policy and chief of staff.
  • Four large regional NCB units and a network of 50 local offices.
  • Around 20 to 25 local, and four large-scale, commissioning support services hosted by NCB.
  • Clinical networks and senates across 12 to 15 ‘core areas’ to support development of services for particular groups of patients.
  • 220 to 240 CCGs.

Emerging details of the NCB’s powers have done little to quieten GPs’ fears over its relationship with CCGs.

GP revealed last week that the NCB may be able to dictate which staff and advisers CCGs employ (GP, 11 April). The groups could be authorised ‘with conditions’ that involve anything from an NCB representative being placed on their board, to the NCB taking away control of commissioning for certain services.

GPC deputy chairman Dr Richard Vautrey says the philosophy the NCB must adopt is ‘to support CCG empowerment rather than build up CCGs’.

He adds: ‘We want CCGs to be empowered and to commission support staff themselves or share them with other CCGs rather than become dependent on clinical support services.’

Dependence on others
But CCGs may be unable to avoid dependence on outside organisations. Dame Barbara Hakin, the NCB’s national managing director of commissioning development, wrote in a DH update last month that there were likely to be 20 to 25 local commissioning support servi­ces and a further four ‘at scale’.

These groups, which will evolve from SHAs and PCT clusters and be hosted by the NCB until 2016, are likely to offer ‘the majority of commiss­ioning support’ from April next year, Dame Barbara predicts.

The NHS Confederation is urging GPs not to be too alarmed at the board’s powers.

Elizabeth Wade, the confederation’s head of commissioning policy, says: ‘These are new organisations. Authorisation is just the first step.

‘CCGs will need to agree on development plans with the board. The principle we want is for the board to use its power in a developmental and supportive way.’

CCGs already cover most of England, and the DH says they hold 59% of their future commissioning budget. But responsibility for commissioning will technically remain with PCT clusters until 1 April 2013.

Four waves of CCG author­isation will start in July, September, October and Nov­ember 2012, with the NCB expecting each batch to take three months.

Dr Vautrey (above) warns that as the dates draw close, there is pressure on some CCGs to complete authorisation before they are ready. He urges practices to beware signing up to hastily drawn-up agreements.

‘Some practices are signing up to constitutions that place far greater responsibilities on practices than is required by their GMS or PMS contract or indeed the Health Act itself,’ he says. ‘They should not be exp­ected to prescribe or refer in a certain way.’

BMA guidance says each constitution should say how member practices can hold the CCG to account.

Health Act detail
The Health Act became law on 27 March but experts say its 473 pages do not fully show how the NHS will look.

NHS Confederation chief executive Mike Farrar says Monitor’s success in adapting culturally to expanding from a focus on foundation trusts alone to all NHS providers will be crucial.

How NCB control over the GP contract takes shape is another area practices will be watching with interest. From April 2013, the NCB will hold GP contracts. Dame Barbara has hinted that this could see it step up PMS reviews (GP, 28 March). CCG control of local enhanced services commissioning will also have implications for practices.

QOF monitoring is also likely to change. Dame Barbara says: ‘The design of local offices has not been completed but there is no assumption that there will be sudden differences. How QOF is monitored is something that we would need to improve.’

Although the Health Act was longer than the legislation to create the NHS, huge amounts of information about what it means are yet to come. Each new revelation may cause fresh alarm for frontline GPs.

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