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Authorisation: end to end

Authorisation: end to end


The first wave of clinical commissioning groups (CCGs) are now authorised and almost all the authorisation visits are completed, with the final one taking place in early January. We are fortunate enough to be able to reflect on the authorisation experience as a whole thanks to our position as a first wave CCG and the time spent as clinical and key assessors for five other CCGs’ authorisation visits.

A vital sideshow
It would be very easy for CCG authorisation to take over and become the sole focus for the whole organisation, yet the real work is continuing to transform health and services for our local communities. We worked very hard to ensure that the CCG’s real work continued throughout our authorisation process – a major re-tender, for example. It would be an overstatement to refer to the authorisation process as a sideshow – we have to be accountable and demonstrate that we are well formed enough to manage the money and the population’s needs – but it is helpful to keep it in place as a necessary hurdle in the course of getting our real goals achieved.

A brief look at the documentation requirements convinced us that we needed a project manager to help us through CCG authorisation. Appointing one at the outset of the process was a good move. It enabled careful co-ordination and linking of the documents and kept everyone to timescale to ensure delivery. We had the advantage of operating in shadow form with full delegated responsibility from the primary care trust (PCT) and a shadow health and wellbeing board that hasbeen in place for more than two years. Even with this background, it was vital to keep everyone in the loop and well informed for the authorisation site visit.

The input of clinicians and managers who were all very willing to put the work in, write case studies and contribute to documentation added to the feeling that this was a genuine team effort.

The desk top review
Having had the experience of our own and other CCGs’ authorisation, it is clear that the desk top review does give a robust view of progress. If one of the 119 criteria cannot be referenced in the documents, it does not mean that no work has been done on it. The review reinforced the helpful discipline of documentation: it is much easier to fudge an issue that has not been written down! Red criteria in this phase of authorisation are likely to be technical,  such as a document may not have been formally approved by the CCG, or concerning a matter of timing where an appointment had not yet formally been made but had been offered.

The authorisation visit
The authorisation visit is an interesting day that can be beneficial to both the CCG and visitors. Our experience, both at home and away, has been that the visit is genuinely developmental with the intent of turning as many red criteria to green as are justifiable. It also gives the CCG a clear steer on dealing with the remaining reds. In our case the visit resulted in 22 reds being reduced to six.
As far as the softer aspects of the visit are concerned there are a few observations worth making.

The chair’s presentation is a vital piece of evidence around progress following the desk top review. It needs to convey a sense of clear vision and aspiration and a grasp of the challenges facing the CCG and their plans to meet them. It has the ability to set the tone for the day and deserves that level of attention. Some CCGs field several people to show their corporacy, however, this can fragment the presentation and corporacy will be clear in the discussions and breakout groups.

The visitors will be looking for passion and enthusiasm about the task ahead for the CCG. If the local leaders are lacklustre, what chance do the rest of us have?

Ownership by all members of the emerging governing body is vital. A GP presenting with clarity about financial aspects or a manager about a clinical redesign can be impressive. If one person responds to all the questions, it does not tend to evidence general ownership.

Moderation and authorisation
Something we only realised during the course of authorisation was how tight some of the turnaround times are for responding. This is where a good project manager with a keen eye for the timescales can really save the day. As a result, we were able to make the necessary responses on time and succeeded in making our case about our red criteria in a convincing manner so that none remained by the time of the final authorisation decision and no conditions were imposed.

Nevertheless, everyone does need to be on the ball to get the responses back in a timely manner.

Challenges and benefits
Our feeling is that the authorisation process has been robust, fair and developmental. The NHS Commissioning Board has been nascent during this period but its few local members have been a helpful sounding board and more than ready to respond to our many questions.

With hindsight, none of us appreciated the sheer scale of pulling together the evidence. There was so much of it and it was in so many different places. Part of this was because we had operated for two years in shadow form and had therefore not produced documentation to authorisation formats. This made cross-referencing the documents to the 119 criteria a major task.

Formalising things in writing was a challenge in keeping it brief and to the point and also an opportunity, as it made us take a very close look at what we do and find ways to improve.

Engagement was a big job and, at times, difficult but well worthwhile. Keeping everyone up to speed can be tricky, particularly when there are hugely varying levels of knowledge and understanding of what CCGs are about. Therefore we could not use common communication for GPs, staff, the local authority, HealthWatch, patients, carers and the public. It meant hard work to ensure we had a good website, email communications, leaflets and meetings. We were very dependent on our communications lead as well as on all our clinicians and managers giving very generously of their time for evening events.

Our learning
If we were to go through the process again, we would like to start to collate the evidence earlier and try to be clearer about the nature of the evidence required and where it may come from.

Perhaps the best thing we have learned is that by pulling together we have been able to achieve something substantial and are now authorised without conditions. That has helped build real confidence to tackle commissioning and not to shirk from the difficult aspects. This was a core value we set out with and the authorisation process has confirmed that we can do this. Now is the time to press hard on the accelerator and use the next two years to prove that CCGs really can transform health and services for our local populations to national standards and better.


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