How CCG authorisation works and what CCGs need to know

England's 212 clinical commissioning groups (CCGs) are embarking on an authorisation process so they can begin work in April 2013 writes Neil Durham.

Dame Barbara Hakin: 'The 212 CCGs have a very significant task ahead.'

Last month NHS Alliance chairman and Devon GP Dr Michael Dixon accused the NHS Commissioning Board (NHSCB) of issuing too much ‘top-down’ guidance and stifling innovation.

England’s 212 CCGs are beginning the authorisation process organised by the NHSCB to ensure they are fit for purpose and ready to take on the role in April 2013 previously performed by 152 PCTs. The process, explained below, includes evidence review, moderation, conditions and decisions.

Dame Barbara Hakin, the NHSCB’s national director of commissioning development, explained the process at the board’s recent meeting in Newcastle last week.

She said: ‘Authorisation makes sure clinical commissioners are properly and adequately supported by the board which is assured that they have all the right competencies to ensure they oversee health services for patients and take responsibility for considerable sums of public money.’

Stage 1: Evidence review

Following the site visit, a report will be prepared and shared with the applicant CCG. It will set out the conclusions of the site visit, both in terms of individual outcomes and assessor views of CCG strengths, areas for development and any areas of concern.

Dame Barbara said: ‘The feedback has been very positive. The site visits carried out so far have gone well. The CCGs undertaking the process say it has helped and been useful in terms of organisational development. The 212 CCGs have a very significant task ahead.’

NHSCB chief executive Sir David Nicholson sat in on a site visit in the east Midlands. He said: ‘You’re not allowed to intervene or speak and they will ask you questions as you go along. I thought it was really impressive. The assessors are very good, experienced health service people and the people from outside the health service commented to me that the training they had been given was excellent.’

For those authorisation requirements which have not been met, the report will cover distance from target and any view expressed by the CCG at the visit as to how they were going to meet particular criteria they recognised they didn’t currently meet.

The CCGs will also be made aware that the site visit report will form the basis of the final evidence report (the main difference being the inclusion of their comments) and therefore decision-making on their application.

They will be asked to consider whether there are any areas where they might be able to make rapid progress over the next three to four weeks, as there will be a final opportunity to submit evidence before their application is considered by the NHSCB sub-committee.

The key assessor, local area team director and authorisation sector lead will then prepare a final evidence report. The content should largely be generated from authorisation knowledge management systems and the site visit report.

The final evidence report will set out the recommended outcomes for all 119 criteria; outline any risks and local context which should be taken into account when determining CCG support needed and set out any difference of opinion between the assessors and the CCG over recommended outcomes.

The report will be completed within 13 days of the site visit and will form the key evidence for the moderation and conditions panels and the NHSCB sub-committee.

Stage 2: Moderation

A moderation panel will review the unmoderated conclusions of the assessment team, any disagreements between assessors and applicants over individual outcomes, results of a number of tests to ensure that appropriate quality assurance is in place and consider outliers where a CCG’s result appears at odds with the national trend. The eight-strong panel includes Dame Barbara.

Panel terms of reference

Review the final evidence report for each CCG and approve the assessment of 119 authorisation criteria before passing to conditions panel, and, make recommendations to the NHSCB sub-committee on which CCGs should be fully authorised and which authorised with conditions.

The panel will meet once per month/wave (October 2012-January 2013). There will be two meetings per wave for waves two and three due to the number of CCGs.

Stage 3: Conditions

A separate panel will be convened to consider what support is required where a CCG has not supplied sufficient evidence to meet a threshold for one or more authorisation criteria.

It is a legal requirement that all conditions are accompanied by an offer of support from the NHSCB. Support could include model document/guidance; advice/expertise available to the CCG; specific team inserted to give in-house support; alternative accountable officer appointed; CCG/NHSCB carries out specific CCG functions or all functions removed.

It is anticipated that a condition could be discharged before 1 April 2013 with only limited support from the NHSCB. It is recommended that a standard review date of March 2013 is built into all conditions. The eight-strong panel will be chaired by Ian Dalton, the NHSCB’s chief operating officer.

The panel will also consider whether a CCG should be authorised with conditions, or established but not authorised as a shadow CCG.

The conditions panel doesn’t review judgements made by the moderation panel.

The panel will meet fortnightly for half a day to consider smaller groups of CCGs within each wave.

The panel makes a report and the CCG has a fortnight to comment, including providing any new evidence that obviates the need for a specific condition.

Stage 4: Decisions

Decision letters will need to be issued immediately after the relevant sub-committee meeting to the applicant. Where a CCG has not been fully authorised it will also set out any conditions imposed, support provided and timescale for review of any conditions.

A rectification plan for each CCG that is not fully authorised would be agreed after the NHSCB sub-committee had made the final decision on authorisation status.

The NHSCB would monitor progress against the rectification plan and would determine whether it was appropriate for a condition to be revised or removed based on CCG progress.

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