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Relating to you

Relating to you
13 November 2013

NHS England is represented on the ground by its area teams. How are relationships developing with clinical commissioning groups?

NHS England is represented on the ground by its area teams. How are relationships developing with clinical commissioning groups?
From 1 April 2013, NHS England took up its full duties to uphold and promote the NHS Constitution and ensure that the NHS delivers better outcomes for patients within its available resources. In the new world of the NHS, with a brand new structure and new commissioning accountabilities, how are the relationships with the new organisations working ‘on the ground’? And in particular, how do the area teams see their role in relation to their local clinical commissioning groups (CCGs)?
First of all, it is important that we are clear on our role. The structure of NHS England works through national, regional and area teams to discharge its responsibilities in a way that supports consistency rather than centralisation; in essence we are NHS England in the locality and represent NHS England across our patch implementing national aims and responsibilities at a local level. Broadly speaking we operate as a commissioner of primary care services, military health services, health and justice services, public health services and specialised services; we also have an assurance role working with CCGs to ensure they commission the best services possible for their local population.
As a commissioner of certain services, we are here to improve health outcomes for our population; we represent and are responsive to patients across the local area, and we ensure patients and the public are at the heart of everything we do. By devolving responsibility to area teams, consistency is achieved in ensuring high standards of quality across the country. 
As well as commissioning primary care for our local population, some area teams have additional responsibilities that they carry out on behalf of their region. For example, NHS England Derbyshire and Nottinghamshire is responsible for armed forces health across the whole of the Midlands and East. To commission high quality care successfully, we, as an area team promote engagement and transparency between all involved in the delivery of health and care services. We work hard to establish and strengthen working relationships with all key partner organisations to ensure that we do the best we can for our local population. 
NHS England operates as co-commissioner with clinical commissioning groups; CCGs make commissioning decisions on behalf of their patients for a vast range of services from a range of providers in their area. Together we need to secure quality today and transform services for the future.
In our assurance role we must support CCGs to be high-performing organisations, providing the right assurance to patients and the public that CCGs are good commissioners. As an area team, our aim is to hold to the mantra of “assumed liberty” by developing an open and honest dialogue about progress and problems that CCGs encounter, rather than a command and control model that would only stifle the enthusiasm and innovation that clinical commissioning seeks to encourage. Early feedback from CCGs is that we are managing this delicate balance pretty well and it means we will only intervene in the few circumstances when necessary. This has required a fundamental cultural shift and a mindset change for many working within the health sector, from the previous top-down approach, and it will take time to mature properly; but the area team is committed to a new style of working with CCGs, working in partnership, not hierarchy.
NHS England Derbyshire and Nottinghamshire is responsible for the assurance of 10 CCGs that commission services for our local population of just over 2 million. The CCGs within our patch vary greatly in size and the population they serve. Southern Derbyshire CCG brings together 57 local GP practices, serving a large and complex population of over 500,000, with both urban and rural geography and demographics. Across the group there is a wide spectrum of social deprivation and differing health needs. In contrast, NHS Nottingham West CCG, with 12 local GP practices serves fewer than 100,000 people in the suburbs and surrounding areas of the city of Nottingham.
Every area team of NHS England has three key roles in working with CCGs in their local area. 
 – A development role to work with and support CCGs to become the best they can be; we work supportively, helping them to make informed decisions, spend the taxpayers’ money wisely and provide high quality services in a consistent way. 
 – An assurance role to ensure as an organisation CCGs deliver the best possible services and outcomes for patients within their financial allocation.
 – A co-commissioning role to ensure direct commissioning undertaken by NHS England works across the care pathway for patients and supports the delivery of local outcomes. 
These roles can be defined separately, but in their implementation they are interlinked.
A key part is the assurance process which identifies how well CCGs are performing against their plans to improve services and deliver better outcomes for patients, as well as working together to assess how they can realise their full potential and provide support on that journey. 
The operations and delivery directorate here at NHS England Derbyshire and Nottinghamshire is responsible for implementing the CCG assurance framework. Balance scorecards are produced and analysed and then reviewed at quarterly checkpoint meetings with CCGs and the area team. 
For practical reasons, the checkpoint and scorecard are based around available and timely data but makes an assessment about the following domains:
 – Are local people getting good quality care? 
 – Are patient rights under the NHS Constitution being promoted? 
 – Are health outcomes improving for local people? 
 – Are CCGs delivering services within their financial plans?
 – Are conditions of CCG authorisation being addressed and removed (where relevant)?
The quarterly checkpoints are a key element of the ongoing relationship between CCGs and NHS England. During these meetings, discussions include an assessment of progress being made against plans. They are also a key opportunity to discuss collaboration around areas of joint interest and developmental support in line with the principle of continuous improvement. Collaboration is essential.
In addition to the quarterly checkpoint meetings, CCGs and NHS England Derbyshire and Nottinghamshire meet on a monthly basis with all 10 CCGs to discuss matters relating to performance and the on-going development of CCGs; this more informal meeting ensures ongoing dialogue about key issues and performance and ensures the quarterly checkpoint meetings have enough time to cover wider strategic issues pertinent to the CCG.
The model of mutual accountability must be anchored within the local Health and Wellbeing Board (HWB). HWBs play a key role in bringing organisations together for the mutual interest of their population. It is the place where all key commissioners of health and social care services come together alongside other vital stakeholders to hold each other to account to local people for their use of public money and the results they deliver.
There is a much greater role for the voice of the patient and other local stakeholders and to support this. CCGs and direct commissioners like us need to support our providers to seek patient and public feedback on their services and to demonstrate how that feedback is shaping service improvement, beyond the Friends and Family Test. This will help us to realise our collective vision of a health system shaped by patient and citizen participation and designed with improved outcomes and patient experience at its heart. 
 1.  NHS England, CCG Assurance Framework 2013/14.

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