Pathfinder Progress - The road to authorisation

Dr Hamish Stedman, Fiona Moore and Scott McKenzie on how their CCG is working at authorisation

Dr Hamish Stedman and Fiona Moore are covering all aspects required for CCG authorisation (Photograph: UNP)

Since the last article, our pathfinder commissioning group, Hundreds Health Salford (HHS) in Greater Manchester, has filled its shadow board clinical appointments. Concerns have been expressed in other areas about appointment processes, but we used a combined selection/election process that all parties, including the LMC, supported.

We are now working towards authorisation, the process by which clinical commissioning groups (CCGs) will be assessed as ready to take on their statutory commissioning responsibilities.

Risk assessment
To be authorised, all CCGs will need to provide evidence across six domains (see box below). The DoH has published a diagnostic tool to help CCGs reflect on their current position and identify development needs, which HHS has used to assess our readiness for authorisation.

The initial stage of authorisation involves undertaking a brief risk assessment. This should be completed by the end of 2011, but across Greater Manchester all CCGs were expected to complete their responses by the end of October.

The assessment has involved grading ourselves as red, amber or green (green meaning we meet the requirements) on a number of key areas:

  • Having a defined geographical focus: HHS has a boundary coterminous with the local authority and developing health and wellbeing board, and all practices in the area are part of the group, so we have graded ourselves green.
  • Be a credible size so that the CCG can discharge all its commissioning functions and duties: The DoH has developed a spreadsheet-based CCG cost tool (ready reckoner), which allows for different assumptions and scenarios of management structure to be costed. While the model has been pre-populated with a running cost allowance of £20 per head of population, this value has not yet been confirmed. We have populated the ready reckoner with our current position and we will be modifying the figures based on what functions HHS wishes to 'make', 'share' or 'buy'. We have self-assessed ourselves as green. It is likely that our local cluster/SHA may revise this to amber.
  • To have in place a constituted membership with full practice support: Again, we have self-assessed ourselves as green. As highlighted in the previous article, we had developed a shadow constitution document that all practice clinicians and managers sign up to.

Dry run
NHS North West has established a 'dry run' to support the process of gathering evidence so that CCGs can demonstrate a 'track record' of commissioning. This will also help determine what CCGs will do themselves and what collaborative and commissioning support arrangements will be needed.

The dry run requires CCGs to lead on a number of areas:

  • Urgent care.
  • Prescribing management.
  • Leadership of quality, innovation, productivity and prevention (QIPP).
  • The NHS Constitution and choice (including any qualified provider).
  • Winter resilience.
  • Elective care.
  • Children's services and young people.
  • Commissioning of programme budget areas (for example, all long-term conditions, including CVD, respiratory disease, mental health and dementia).
  • Levelling up quality in primary care.
  • Collaborative commissioning.
  • Contracting and planning round 2012/13.

We have strong clinical leadership in the majority of areas, but further work is required on winter resilience, collaborative commissioning and the technicalities of contracting and planning. Although this is being referred to as a dry run, it is the method by which actual evidence will be collated for the authorisation process.

Authorisation process
It is expected that there will be three elements of the authorisation process (see box below). The expectation is that the NHS Commissioning Board (NCB) will receive the earliest applications for authorisation in summer 2012.


To be authorised CCGs will have to demonstrate the following:

  • Strong professional and clinical focus.
  • Meaningful engagement with patients, carers and their communities.
  • Clear and credible plans to deliver QIPP challenge.
  • Proper constitutional and governance arrangements.
  • Collaborative arrangements for commissioning.
  • Individual and collective leadership.

It is expected the process of authorisation will involve the following:

  • Submission of evidence, which will include the commissioning plan, constitution, prospectus and organisational development plan. It may also involve submitting personal development plans for clinical leads.
  • 360-degree review and technical assessment and analysis of commissioning and financial plans, along with working arrangements with stakeholders and practices.
  • Interview/panel that will likely involve the CCG board and local stakeholders.

There are three possible outcomes: being designated a shadow CCG, authorised with conditions and fully authorised. HHS will aim for 'fully authorised', provided no unrealistic targets are set for running costs.

HHS is aiming to complete its application by July 2012, although the earliest we would take up statutory duties would be April 2013.

Forthcoming challenges
Along with authorisation, there are other challenges on the horizon. Our local health and wellbeing board is fairly advanced and HHS is a major stakeholder. However, this is a new way of working and we will need to work hard to develop new and effective relationships, especially where the organisations involved have different financial challenges.

In addition, there are concerns about the development of commissioning support services and we continue to work with uncertainty about the running costs envelope. HHS is keen to retain local talent and their knowledge and relationships, but there are pressures to develop commissioning support services, both for all neighbouring CCGs and the NCB. We continue to wrestle with the tensions between local versus clustered commissioning support, mindful both of economies of scale and a finite talent pool.

  • Dr Stedman is the lead GP and Fiona Moore is head of clinical commissioning at pathfinder CCG HHS.
  • Scott McKenzie is a business consultant specialising in commissioning support

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