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Small is beautiful

Small is beautiful
24 September 2012

West Berkshire is a relatively self contained Health Economy with four small clinical commissioning groups (CCGs) clustered round two major providers, The Royal Berkshire NHS Trust providing most acute services and Berkshire Healthcare Trust providing most mental health and community services for the population of 497,400 served by 55 practices.

West Berkshire is a relatively self contained Health Economy with four small clinical commissioning groups (CCGs) clustered round two major providers, The Royal Berkshire NHS Trust providing most acute services and Berkshire Healthcare Trust providing most mental health and community services for the population of 497,400 served by 55 practices.

A 2010 scoping exercise by practice based commissioning (PBC) leads and the primary care trust (PCT) a whole PCT CCG was proposed, which was
rejected by practices on the grounds that this would just replicate the PCT.  To utilise the opportunities created by the new Act we needed smaller CCGs that could focus on engaging practices and creating real member organisations that were different from PCTs.

Our stance has been partially vindicated in my own CCG of 10 practices where we have seen substantial falls in radiology, pathology and prescribing costs as we explore clinical practice variation in a small cohesive group with a history of working together.

Oxfordshire, our neighbour has a CCG of 84 practices and a population of 685,100, uses a locality structure – smaller local groupings of practices which work together led by a GP, to foster local engagement.

It will be interesting to compare our effectiveness over time with their entirely different approach. If our belief that small is beautiful proves wrong it will be easier to merge small CCGs than demerge a large one.

Following the practice’s rejection of the whole PCT CCG we developed four small CCGs:

•    NHS North and West Reading CCG:  
    –    10 practices.
    –    106,000 population.
•    NHS Newbury and District CCG:
    –    11 practices.
    –    112,900 population.
•    NHS South Reading CCG:
    –    20 practices.
    –    125,300 population.
•    NHS Wokingham CCG:
    –    14 practices.
    –    153,200 population.

While there have been reports from other areas of the strategic health authority (SHA)concerning pressures for small CCGs to merger, our effective federation structure has protected us from such pressures and allowed us to offset some of the disadvantages of small size, the most pressing of which is the £25 per head management envelope, while developing the clinical engagement that will be crucial for CCGs to succeed.

A key principle of our federation is that the CCGs are in charge (mirroring our CCG constitutions where practices are in charge). Inevitably that will mean compromise, but no CCG can be told by the federation what to do.

The federation is not a legal NHS entity and its power is derived from the four CCG boards, channeled through the four CCG leads and shared accountable officer. It will have no resources of its own although shared posts will be funded from a levy from the four CCGs and hosted within a single CCG.  

All statutory responsibilities are discharged by the individual CCG although they may be enacted through a shared post. For example, the named nurse may be shared across the federation but the CCG is responsible for safeguarding.
The federation structure enables us to:

•    Assist each CCG to fulfill its statutory duties in an effective, efficient and economical way.
•    Achieve value for money through reduced cost and economies of scale.
•    Maximise influence of CCGs with large providers;
•    Share risk.
•    Maximise ability of each CCG to access skills and capabilities they could not access by working alone.
•    Achieve consistency and integration where a pan CCG approach is required/desired.
•    Allow the CCGs to focus on clinical engagement by every health professional working for it.

The federation is being developed through a federation development group consisting of:

•    The four CCG chairs.
•    The PCT’s director of commissioning seconded to the federation and will be replaced by a shared accountable officer in June.
•    The PCT’s finance director, who is currently seconded in to East and West Berkshire federations and will be replaced by a single chief financial officer for West Berks Federation in July.
•    The transition director for Newbury and North and West Reading CCGs.

The following posts will be held within the federation:

•    The federation chair.
•    A GP lead from each CCG usually the chair unless he is federation chair in which case his deputy CCG lead.
•    Shared across all four CCGs:
–    The accountable officer.
–    The chief financial officer.
–    Deputy finance officer.
–    Head of joint commissioning shared with three local authorities.
–    Administrative coordinator.
–    Personal assistant to the accountable officer, chief financial officer and federation chair.

The federation is chaired by a CCG chair, whose GP deputy lead also attends. We had considerable debate about potential conflict of interest between a CCG chair being federation chair also but decided that as the federation is more a coordinating position and the power lies with the individual CCGs that this was acceptable.

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The federation chair attends meetings with the SHA and other partner organisations and represents all four CCGs. We considered whether a non-CCG chair could chair the federation but felt that they could not represent the CCGs at meetings with bodies like the SHA or NHS Commissioning Board (NHSCB), as their knowledge would be inadequate. All four CCGs are levied to cover two GP sessions a week for the chair, who is elected annually.

A GP lead from each CCG takes responsibility for leading a category of care and contract:

•    North and West Reading – urgent care and private providers.
•    Newbury  – planned care and Royal Berks Contract.
•    South Reading – long term conditions and mental health contracts.
•    Wokingham – joint commissioning and children’s services.

The shared posts will allow us to offer an attractive remuneration package which, with the possible exception of Wokingham, would not be possible for small CCGs.

We are in discussions with three local authorities covering West Berkshire about a shared head of joint commissioning, who will take responsibility for developing the three local authority led health and well being boards. The accountable officer cannot be appointed till the end of June when they have completed their NHSCB CCG assessment. Once the accountable officer is in place substantive appointments to other roles within the federation and CCGs can be made.

The GPs are elected by their peers and we plan to share a federation board nurse with working nurses from within each CCG leading on engagement, possibly as an extra CCG board member.

The consultant board member needs to be from a hospital not commissioned by each CCG and we are advertising this role in the BMJ.

The executive teams within the CCG will be tiny:
•    A quarter share of the federation staff.
•    An operations director.
•    A business manager/ executive assistant.
•    An Admin Assistant per CCG.

Both the Federation and the individual CCGs are small organisations and much of the detailed work will be done by the commissioning support unit, formed from a merger of several PCT clusters including Berkshire’s.

Our proposals can just about be delivered within £25 per head. Initial indicative running cost allowance figures from the NHSCB suggest that one of our CCGs will receive more than £25 a head while two will receive less than £23 a head as adjustments have been made to practice populations using Office for National Statistics population figures derived from census data.

We have had excellent facilitation from Attain, a private sector company to develop our joint working with our commissioning support service (CSS) and have signed a service level agreement with the CSS with further ongoing work from a GP lead from our federation to agree the fine details of CSS support and funding.

Apart from the CCG boards all subcommittees will be shared including:

•    Commissioning committee.
•    Quality committee.
•    QIPP and performance committee.
•    Audit committee.
•    Remuneration committee.

One of the reasons it is proving difficult to provide an adequate organisational structure within the £25 ahead management cap is that GPs quite reasonably expect GP level payments, not lower cost locum pay. GPs are crucial in delivering pathway change and clinical engagement from their peers.
Our PCT cluster has engaged a solicitor to write in plain English a CCG constitutional template for each CCG to adapt with a federation memorandum of understanding as an annex. We are asking our practices to sign the constitution for our first wave authorisation process by the end of June.

Our well developed federated structure is one of the reasons that the SHA has allowed us to apply for first wave.

Each West Berks CCG had most of the PCT’s budget devolved to it in 2011-12 and has achieved a surplus at year end. My own CCG has ended the year with the following savings achieved by reducing clinical practice variation.

•    £300,000 on reducing referrals in to secondary care
•    £100,000 on pathology
•    £50,000 on radiology
•    £100,000 on running costs
•    £400,000 on last year’s out turn on prescribing costs

Creating a federation carries extra costs of running a separate board for each CCG, but we believe that these costs are outweighed by the clinical engagement that smaller CCGs can achieve. It may be possible when our rather fragile clinical engagement is cemented to merge thesefour CCGs into a super-group CCG of 55 practices.

By working together and sharing personnel within a federation with shared staff and subcommittees we have managed to defray much additional cost whilst developing the clinical engagement that is crucial for CCGs to succeed.  

Dr Rod Smith, chair of NHS North and West Reading CCG, Chair West Berks Federation of CCGs and Reading GP

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