As we all know by now, primary care trusts (PCTs) will be abolished in April 2013. At the same time the NHS Commissioning Board (NHS CB) will become fully operational with 27 local area teams (LATs). Seasoned NHS-watchers probably expect the latter to be simply a rebranding of the former. Poppycock, says Commissioning Czar Dame Barbara Hakin.
As we all know by now, primary care trusts (PCTs) will be abolished in April 2013. At the same time the NHS Commissioning Board (NHS CB) will become fully operational with 27 local area teams (LATs). Seasoned NHS-watchers probably expect the latter to be simply a rebranding of the former. Poppycock, says Commissioning Czar Dame Barbara Hakin.
“There is a really big difference… this is a completely new board; a single-operating model,” says the Director of Commissioning at the NHS CB. The LATs will have three key roles she says: direct commissioning on behalf of the NHS CB; the oversight of CCGs ensuring that they are delivering the best outcomes for their patients; and relationship managers across their patch, understanding the broader perspective of both providers and commissioners.
Oversight is a word that may concern CCG leaders. Rest assured, says Hakin.
“Because the majority of people running CCGs now have always worked on the basis of being a practice-based commissioner on the sub-committee of a PCT and have only had delegated authority, most of them don’t understand how autonomous they will be when they are a statutory body.
“The sovereignty of a CCG and its ability to do its own decision-making, providing it is delivering better outcomes and better value for money, will be that of any statutory body.”
So as long as CCGs are reporting better outcomes (which will be measured against those areas identified by the NHS CB from the commissioning outcomes framework) how they go about achieving them is up to them.
There will of course be levers the NHS CB will have at its disposal such as conditions on authorisation, and of course the quality premium.
“The quality premium is still work in progress,” says Hakin.
“I think it will be for the NHS CB to determine what happens based on the Act and regulations that follow. The quality premium will only be paid in 2014 because it’s based on the previous year, so the earliest we’ll be able to calculate it all will be 2014. I realise people are frustrated [by how long it’s taking] but we are working on it.”
It has, however, been announced that the quality premium could be up to £5 per patient head and Secretary of State for Health, Andrew Lansley, set out a draft mandate to the board in July which stated that the money would come from the ‘overall administration costs limit set in directions for the NHS commissioning system’.
As well as the focus on authorisation, Hakin is looking to ensure commissioning support services (CSSs) are the best they can be. “In order to support CCGs I believe that unless wwe get economies of scale in commissioning support, there won’t be the space or the resource to support the clinical aspect of commissioning.”
So how will a CCG with a relative lack of management experience recognise a good CCS from a bad one?
“I think in the early stages the vast majority will secure their commissioning support from their local organisations. The clinical support services that will be hosted by the board will be kept at arms’ length and will be separate from the LATs… The end point has to be that CCGs can chose their commissioning support from wherever they wish, and in the early stages I am sure CCGs will choose bits of commissioning support from the independent, the private and the voluntary sectors. But for the most part, when CCGs are in their infancy, the vast bulk of commissioning support is sitting with people who have been in PCTs for years.”
So, even though the majority of CSSs will come from former PCT staff, they will not be directed by the NHS CB. However the board will host these CSSs until the end of 2016 meaning that it will make sure that ‘services operate effectively, with the right customer focus and with sufficient buy in from local CCGs’.
Beyond that they will be independent organisations, free to take whatever form suits them best.
As for the private sector, it is only making inroads into CSSs where it is partnering with the NHS.
“I think that often the independent sector offer niche products, tools that help you to commission, and actually where we are seeing real progress is where some of the NHS commissioning support services have a partnership with the private sector.
“We think there are seven or eight thousand people who will be involved in the NHS commissioning support services hosted by the board. The private sector wouldn’t have that capacity but actually when you start to bring those people and their capability and understanding together with the private sector tools and resources, then that’s when you get change.”
Clearly the reform process has been laboured and momentum, at points, inevitably flagged. Policymakers know that GPs need to be onside if the reforms are to succeed but relations between the two camps have been strained over the health reforms and changes to pensions. However Hakin feels that it’s not up to the centre to embark on a hearts and minds campaign but rather it should be done locally.
“I think the very reason we have got local organisations called CCGs is that it’s up to them to engage the hearts and minds and the NHS CB will support them any way it can in terms of tools or guidance or sharing best practice for engaging both clinicians in and out of practice, patients and the public.
“CCG leaders are the ones. You can’t engage people in a CCG by saying something on a national platform. It’s about those CCG leaders demonstrating their leadership and helping to persuade their member practices that this is a membership organisation, that they need to be involved and then the clinicians in the practice starting to work with their local population. So that winning of hearts and minds – there is a limit you can do nationally.”
“I think people want to see this coming alive and not to hear a discussion about it. I think it’s about us being able to demonstrate where in the country CCGs are making a real difference.”
But inevitably there will be those GPs, disillusioned by pension changes and fatigued by the reforms, who are resolved to carry on doing what they have been doing, providing clinical care to their patients while giving the CCG as wide a berth as possible. How will the board react to those practices?
“I think that by far and away the most important question is, is this practice providing good primary care? Because if a practice is providing good primary care then it won’t have a higher than average emergency admission rate and its prescribing will not be way out of kilter with everyone else. I think the question is much more how do CCGs and the board work together to identify those areas where poor practice is having an impact not only on the provision of care but on the commissioning of care.”
Ultimately if a practice is a problem it is the NHS CB that will get involved.
“It’s critically important that everybody understands the contractual relationship is with the board.”
And Hakin points out that CCGs will have the quality premium to use as a financial lever to reward practices who deliver better outcomes. They will also be looking to invest in additional services from practices and will inevitably look at getting those services “from those practices you were comfortable were providing good quality general practice in the first place”.
So while there will be no formal discipline for not getting involved, it is likely that benefits will be missed. A further area of concern is conflict of interest. How will a CCG negotiate commissioning a service out in the community where it’s own members will be the providers.
“What we want CCGs to do is define and commission more local services. Who is the provider of that service is then something we have to go through to determine who that might best be, because there’s no reason why secondary care providers, independent providers and voluntary sectors can’t provide community-based services.
It’s clear that Hakin feels a CCG, to be authorised and to succeed must make use of seasoned NHS managers. She says that CCGs will better cope with the rigours of being a statutory body if they include “very senior managers who have worked at corporate board level within NHS organisation” adding that the NHS CB “during authorisation will certainly be looking to see that CCGs have that level of understanding somewhere in their organisation in their senior management”.
“Speaking from a personal point of view, having been a GP to working in a corporate entity, I do recognise that there is a lot more you need to do in a corporate entity. That you need to demonstrate that everything you do is open, transparent and above board.”
But when it comes to making the tough decisions about provision, it is the clinicians who will face the public.
“The evidence shows that CCGs are really motoring on their relationships with their communities. Some of them have done some sterling work already on the nature of services. You know we’ve seen lots of protests for services which, actually, the majority of professionals think aren’t safe. We are starting to see CCGs having a real conversation with their patients and public representatives which actually helps the public to understand how they can get the best care. So I hope that CCGs will be really out there, really explaining to people the evidence.”
Where those decisions are protested by patients in clinic, Hakin speaks about “throwing a blanket of support around individual practitioners” providing guidance on how to respond. Hakin’s final priority, along with authorisation and getting CSS up to scratch, is “working out all the things the board could do, the tools and guidance, that we could wrap around that system in order to make it the best it could be.”
