National director for commissioning strategy at NHS England Ian Dodge told GP new flexibilities around incentive schemes being introduced under CCG co-commissioning powers next April will allow commissioners and GPs to innovate to respond to local needs.
Mr Dodge rejected fears that allowing practices to opt out of the national QOF and adopt local schemes would lead to inconsistency in services available from area to area.
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There was already inconsistency under the current arrangements, said Mr Dodge, and allowing more flexibility would ‘create space’ for CCGs to innovate and respond to local needs and priorities. ‘I would argue that one of the reasons why we have that variation is a lack of innovation in some of the delivery models,' he said. ‘What we are looking to do in the Five Year Forward View more generally is to try and create that opportunity for new, more innovative models to develop to tackle those variations.’
Consistency of services
NHS England will be able to set national 'standing rules' to help ensure services are consistent.
GP leaders have warned practices that they could still be performance managed on QOF indicators even if they opt out into local arrangements, meaning more work for the same money. But NHS Clinical Commissioners co-chairwoman Dr Amanda Doyle suggested that may not be the case. ‘I don't think we know what CCGs will decide to do about this yet,' she said.
‘The pilot scheme in Somerset's going on at the present time - I think CCGs are likely to want to look at the outcome of that and make decisions about whether they want to flex QOF locally or add extra incentives locally, and I think it's important we learn the lessons from that. It will be up to local CCGs how they performance manage outcomes for their practices.’
CCGs will be able to choose one of three models of co-commissioning: greater involvement, joint decision making, or delegated responsibility.
Guidance issued by NHS England on Monday revealed the full extent of powers that can be delegated to GP-led CCGs from April 2015.
Under the fully delegated model CCGs will be able to manage contracts, including designing PMS and APMS deals, taking contractual action such as serving remedial notices and removing contracts.
Local decision on enhanced services
CCGs will have power over locally agreed and nationally set enhanced services - LESs and DESs - and the design of local QOF alternatives. They will be able to establish new practices, approve mergers and award discretionary payments, NHS England has revealed.
Dr Doyle reiterated that if a practice wants to continue to paid under the terms of the national QOF deal, ‘that is its right and entitlement’.
The new guidance set out statutory measures to guard against conflicts of interest including demanding a lay and executive majority on CCG decision making committees, observer rights for a HealthWatch and health and wellbeing board member, and public registers of interests and procurement decisions.
Dr Doyle said despite handing decision making power to lay-majority committees, clinical commissioning would be ‘alive and well’ in primary care commissioning.
‘You can still have clinicians on that committee to help directing strategy, making the decisions, but they would not be in the majority. I think that is essential so we can be absolutely transparent about conflicts of interest. It doesn't change the makeup of the CCG governing body, or clinical input to any other decision making.’
Mr Dodge said lay members already had good knowledge and experience of handling conflicts of interest and would be given more training.
He added: ‘We think we've got a way here of squaring the circle. Of not changing the core, fundamental governance arrangements and insisting on a national approach around increased numbers of lay members, whilst also really protecting against very real conflicts of interest challenges that CCGs are mindful of, and unless we find a way of getting that right, it will be really difficult, I think, to achieve the Forward View vision.’
