The holistic approach

South Warwickshire was awarded delegated authority and because of this, healthcare organisations in the area can now be brought under one umbrella

In NHS South Warwickshire Clinical Commissioning Group (CCG), we have a strong belief in a holistic approach to healthcare commissioning where a joined-up local health and social care system can bring tangible benefits to the health of our population. Our decision to take on delegated commissioning (when a CCG assumes full responsibility for commissioning general practice services) for primary care co-commissioning stemmed from this belief and is a logical next step in our evolution as a CCG. We believe this allows us to take more control of our own destiny.

About us
The CCG came into full operation in April 2013. Our CCG is made up of 36 GP practices and covers a population of 275,000 people over the wide and diverse geographical area of Warwick and Stratford-upon-Avon districts. Being GP representatives from practices as diverse as bustling Leamington Spa to rural Shipston on Stour we feel we are closest to dealing with people’s healthcare needs on a daily basis and this, together with our responsibility for leading the CCG, ensures that everything we do provides real benefit to the public.
Currently, our responsibilities include commissioning services from partner organisations such as South Warwickshire NHS Foundation Trust (SWFT, for acute and community services) and Coventry and Warwickshire Partnership NHS Trust (CWPT, for mental health and learning disability services). We also work in close partnership with Warwickshire County Council to ensure healthcare, public health and social care services are joined up. Additionally, we deal with other groups such as charities, education providers and community organisations to make sure as many people as possible have their voices heard.

Primary care co-commissioning
This delegated commissioning option offers an opportunity for our CCG to assume full responsibility for commissioning primary care services (for 2015/16 our scope will be general practice services only). As with all CCGs that have delegated authority, the liability for primary care commissioning remains with NHS England. This shift in responsibility from NHS England provides us with new opportunities to deliver our strategy which is to improve the lives of our local populations through transforming our health and care services.
Key to the delivery of this strategy is shaping primary care so it is fit for purpose for the future and supports our desire to start to move services from a hospital setting to an alternative place of care.
We will of course continue to work closely with NHS England who continue to directly commission the remainder of primary care (pharmacy, dentists and ophthalmology) and specialised services, military and offender health services.
With NHS England’s support, the CCG has taken on the full list of functions suggested as the most suitable for full delegation. These are:

General medical services (GMS) and personal medical services (PMS) contracts.
Enhanced services.
Property costs.
QOF (quality outcomes framework).

This is an exciting development for South Warwickshire CCG, as we believe that clinically-led commissioning of primary care could potentially lead to a range of benefits for the public and patients. We aim to improve access to primary care and wider out-of-hospitals services, with more services available closer to home. South Warwickshire CCG will now have the ability to design, procure, and re-specify
high-quality services to reduce variation and improve quality in primary care through the direct management of existing contracts and future development of new contracts. We will also have the ability to more creatively use the financial allocation to support delivery of flexible and appropriate out of hospital care. In turn, these changes will lead to improved health outcomes, equity of access and reduced inequalities. Our patients will experience more joined-up services, due to simplifying communications, conversations and improved engagement and involvement directly with GPs and their practices. In a nutshell we can use our local knowledge combined with the flexibility delegated responsibility offers to deliver top quality and value for money solutions that are right for our population.
Engagement with stakeholders has been absolutely vital to our development as a CCG and this remains the case as we take on primary care co-commissioning. Wide ranging engagement with patient groups, Healthwatch Warwickshire and the Warwickshire Health and Wellbeing Board has taken place regarding the development of a model for primary care. While recognising the risks, particularly around perceived conflicts of interest, all our stakeholder groups were strongly in support of level three delegation. They too see it as a tool to drive change and welcome our decision to take on this responsibility.

Managing risks
During our consultation with all the GP member practices in the CCG we used existing communication channels to discuss the options available to us. Our well established and attended CCG Members’ Council offered the best forum for debate, and over the second half of 2014 conversations were held and three main risks were identified. These were:

Perceived or actual conflicts of interest.
Management capacity or capability.
Budgetary pressures.

Once identified, actions were put in place to alleviate these risks.
A Primary Care Commissioning Committee has been established. Its role is to make decisions on the review, planning and procurement of primary care services in South Warwickshire under the delegated authority from NHS England. In the first meeting of the Primary Care Commissioning Committee, held in April 2015, we discussed the governance arrangements for the committee, the 2015/16 budget, primary care infrastructure bid applications and the application for the Prime Ministers Challenge Fund. These bi-monthly meetings are chaired by our recently appointed lay member and are held in public.
CCGs are already proficient in handling conflicts of interests as part of our day-to-day work. We are aware that co-commissioning may well lead to an increased number of conflicts of interest for CCG governing bodies and GPs in commissioning roles. Rigorous and robust processes have been put in place to deal with such conflicts. A risk management strategy has been developed, including a revised conflicts of interest policy (in line with national guidance), an additional CCG based senior manager, and separate budget lines for primary care contracts and related expenditure. The CCG has revised its constitution to reflect the proposed changed and has also recruited recently two new lay members to support the establishment of the Primary Care Committee.
Over the coming months we will be working to embed primary care
co-commissioning into all aspects of our work in order to ensure that we can truly create a holistic approach to commissioning. Our Future of Primary Care (see Case study) project is the flagship piece of work for this and with the involvement of our members, partners and patients I am convinced that we will be able to maximise the benefits of co-commissioning for the wider benefit of our population.

Case study – Future of Primary Care programme
A major project we are focusing on is the development of a future model of primary care that will have the capacity and capability to deliver more, increasingly complex care outside hospital. We have been particularly looking at accessibility, methods of delivery and community-based integration of services. In a recent survey, 357 South Warwickshire patients gave us their views on current experience of primary care services and provided suggestions for improvements.
When asked about the use of technology in surgeries, 80% of patients surveyed told us that they were happy to have a telephone appointment. The majority of patients were prepared to travel for face-to-face appointments, with 37% of respondents prepared to travel up to five miles. There was a strong feeling from patients that they want a seamless service, with continuity of care, as patients move through the health system and the importance of ‘telling your story once’. Seventy seven per cent of patients said they would be happy to attend an appointment at another practice in order to receive an evening or weekend appointment.
In a complementary survey of GPs, we had responses from 26 out of our 36 practices. The results were that 100% of respondents already offer telephone appointment, 19% offer appointments before 8.30am, 73% offer appointments after 6.30pm and 61% offer weekend appointments. In the future 46% are interested in trialling Skype or webcam and 84% are interested in email appointments but were concerned about language barriers with some patients. Only five practices said they either currently, or had in the past, shared services with other practices. These services included leg ulcer treatment, minor surgery, coil insertion, practice management services, ophthalmology and an anti-coagulation clinic.
The feedback is the initial stage of a thorough and wider review of our primary care services, which we are running alongside a review of community services as the two are interlinked. The CCG’s draft primary care strategy is focussed on continuous improvement in the quality of general practice, ensuring consistent basic standards while differentiating services on a locality basis to meet patient need. In order to deliver this, the CCG is exploring alternative models of primary care that may reduce or change the number or nature of contracts moving forward to support greater integration with the wider out of hospital system.

Dr David Spraggett, chairman of NHS South Warwickshire CCG.