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Feature: Grey Area

Feature: Grey Area
3 June 2014



May 2014 saw NHS England’s new chief executive, Simon Stevens, announce a new option for local clinical commissioning groups (CCGs). They will soon be allowed to co-commission primary care in partnership with NHS England.
NHS England hopes to give the 211 CCGs new powers to improve local health services under the new commissioning initiative.
Mr Stevens said he wanted CCGs to have a “greater influence over the way NHS funding is being invested for their local populations.” 
“As well as new models for primary care, we will be taking a hard look at how CCGs can have more impact on NHS England’s specialised commissioning activities.”
NHS England will invite CCGs to submit expressions of interest in taking on enhanced powers and responsibilities to co-commission primary care.
Applications will need to describe the additional powers and responsibilities the CCG would like to assume. They will need to meet a number of tests, including showing they will help advance care integration, raise standards and cut health inequalities in primary care.
They will also need to show how they will ensure transparent and fair governance – with a continuing oversight role for NHS England to safeguard against conflicts of interest.
This latest announcement can perhaps be seen by NHS England as an admission that they cannot do everything.
It is fair to say since the creation of CCGs and NHS England local area teams there has been mounting criticism of the role of the latter in their relationship with CCGs and the direction they are supposed to take in developing and assuring the work of the former. There is also even more criticism in how they are contracting from GPs for the provision of primary care services.
President of the National Association of Primary Care and a GP in the Wirral, Dr James Kingsland, is critical of the way NHS England’s area teams have developed.
“There does seem to be a situation where area teams are trying to performance manage CCGs and they have no role in that… it seems to be that CCGs are having to face area teams like primary care trusts (PCTs) faced strategic health authorities (SHAs),” he admits.
He points to the fact that many of the senior managers in area teams come from the old PCT and SHA guard.
“If only we could replace these senior managers. Simon Stevens needs to hear this. These are supposed to be new organisations with new relationships but there is not really a new approach to them.”
“NHS England need to give clear directives about what NHS England are there for,” he adds.
“If we are going to get collaborative commissioning sorted out this has to be on an equal footing.”
“Dr Michael Dixon, president of NHS Clinical Commissioners agrees that some area teams are “behaving rather like bossy PCTs”.
“Some have got the plot and understand that decentralisation is the thing and are linking with the CCG rather than acting like the NHS police force in general CCGs are still seen as second class citizens by the centre.” he says. He also warns that area teams are stretched to capacity. 
“Sometimes it feels very much like they are having their reigns pulled from the centre…and some of it is down to their size and resource, they are skin thin and overloaded with work.”
Charles Alessi, chair of NHS Clinical Commissioners, describes the relationship between CCGs and area teams as one that is “maturing”.
“The relationships have been uneven but that is inevitable because we still have a lack of clarity between the different roles and responsibilities. In terms of co-commissioning primary care there has been a different view as to the levels of involvement needed between CCGs and area teams.”
Mr Alessi is clear though that the relationship between CCGs and area teams need to be one that is based on respect and not that of a parent and child. He suggests that now might be time for those based within either CCGs or area teams who had come in to the organisations from PCTs and SHAs to consider whether they were “comfortable working in the new world.”
Dr Agnelo Fernandes, assistant clinical chair at Croydon CCG, says that area teams also needed to take a “less risk-averse mindset” when it came to working with CCGs.
“The majority of area teams are staffed by non-clinicians and I think they need to develop their capacity and capability for innovation and for taking risks,” he says.
However, many CCGs are not just critical of the relationship between themselves and area teams, but also of the relationships the area teams have established with the GPs they are commissioning services directly from.
Dr Fernandes describes the operational relationship between the area teams and primary care providers as a “black hole,” and says that when it comes to the administration of this relationship, he says “take the black hole and treble it”.
“Payments are late and confused and lots of practices are suffering financial difficulties as result,” he explains.
“There is a constant battle going on between practices in their provider role and their relationship with the area teams who are still working in the old world and who simply do not have enough or budget for this.”
He says that some CCGs are trying to broker the relationship between the two and help out as best they can but that this is not part of their official role.
Ruth Robertson, health policy fellow at the Kings Fund, warns that GPs on the ground are not “really having any contact with the local area teams which are supposed to be managing their contracts.”
“The area teams don’t have the resource they need to fulfill their role in commissioning and lot of CCGs we have spoken to are doing the contracting work that is the job of the area teams,” she explains.
How these relationships will develop only time will tell.Last November, NHS England published assurance frameworks for CCGs and direct commissioners.
The frameworks set out how NHS England will assure that CCGs and NHS England’s own direct commissioning functions are operating effectively.
At the time NHS England admitted that while CCGs had an established, consistent baseline of expected performance through the authorisation process, the assurance of services directly commissioned by NHS England’s area teams is at an earlier stage and will begin with a comprehensive baseline exercise using the CCG authorisation criteria.
The Department of Health says it will also conduct an annual assessment of NHS England’s performance including the extent to which it has met the objectives set out in the Mandate. The first annual assessment could make for interesting reading. l
Helen Mooney is a health reporter.

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