After just over a year of operation, it’s time to take a look at clinical commissioning group challenges, opportunities and what the future holds. The Commissioning Review invited key stakeholders to discuss this topic in terms of governance, conflict and assurance.
Moosa Patel: We have done a lot of work over the past few months with two very contrasting clinical commissioning groups, one serving a large inner city community and the other a mixture of rural and urban. We have been looking at their corporate governance arrangements and identifying both strengths and areas for development. We have been pleased largely with what we have seen. There is a really strong desire in both CCGs to be a clinically-led commissioning organisation. They’ve made good progress in their first year and they have a strong governing body. They have a good understanding of corporate governance and conflicts of interest, which I thought was going to be a real nightmare and that might be the case elsewhere, but certainly in these two CCGs it has been working quite well. Challenge and oversight on the whole is good as is etiquette at governing body meetings.
The dialogue between primary and secondary care clinicians has been excellent in both CCGs. The governing body is diverse and their commitment to openness and transparency as well has been really good, with very little being done in private board meetings. Indeed we have observed many elements of good corporate governance which we have not seen in more established NHS provider organisations.
On the flip side, we have observed a number of areas where we have had concerns…the lack of good quality information on performance, finance, quality and safety has been a real issue.
The other area that has been an interesting weakness is that they have very good committee structures, but the feedback into the governing body has been quite weak and as a result the oversight by the governing body does not seem to be there. That feels to us to be an area that needs sorting out.
Jag Dhaliwal: I am lucky enough to go and visit various CCGs in terms of building relationships, and some quarters are coming out in front….You see it in the attitude more than anything else. I think there are some colleagues who still feel they were corralled into being CCGs and it is a shotgun marriage and you never really wanted it, so it is your professional ethics and duty to try to make the thing happen but you really do not want it. Others are much more willing to give it a go and there is open mindedness.
Hasan Chowhan: When there is stability in leadership and fixed roles then, going forward, you get some buy in to the organisation and then you get development…I think CCGs need to be open to criticism and challenge and welcome that. If they are not having meetings in public that is something that needs to be put forward to try to entertain that, because otherwise you will not really identify those development possibilities.
John Morton: The CCG governing body is a new type of board with different relationships between chair and chief officer and it is a clinical board, so it is very different from a primary are trust (PCT) board or an SHA board or the NHS England board and I think unless you are sitting on one it is difficult to understand the difference. It is not a pre-set meeting. It is very much a clinical discussion and the outcomes are not always what you might anticipate the outcomes being, which I think is a real positive. Getting the balance right between it being a clinical board and having some managerial input I think is an on-going challenge.
Leon Douglas: My sense is that it is all very well and they are doing their job, but the real power for us does not come from the governing body but from the level below that, our clinical leadership group. It is a very robust forum. They are quite happy to share their views if they disagree. Most of the input from that comes from our networks, so they can be real hothouses of discussion. You need all the checks and balances, do not get me wrong, and our governing body are very confident in being able to do that, but where we have started to really gain momentum is where the networks and the clinical leadership group to support them have started to push things forward.
Jag Dhaliwal: For us, locally, not many clinical decisions come to the governing body. They are at committees below which are given delegated responsibility, but those committees do not then always get the benefits of [the] organisation or development.
Victoria Vaughan: Conflicts were mentioned by Moosa and I was wondering, James what your experience is around this area?
James Clarke: It is incredible the shift of attitude that we have seen right from the start as the development of an effective conflicts management policy brings a problem to be managed or simply a legal tick box exercise, to what is now considered to be a part of a very well developed governance system; one of the tools that can be used to empower effective commissioning. If a clinical lead of a CCG is involved quite deeply in the specification design of a service that is to be commissioned, 10 months ago the question would have been asked ‘that person surely cannot be involved in the assessment process of bids’ or ‘what happens if they are involved in a provider company, surely that excludes them either from inputting their design or participating in a bidding organisation’. Whereas now I think the regulatory framework that applies to management of conflicts and competition has also assisted in the development of effective governance policies in order to deal with that.
Hasan Chowhan: I am sure everybody around the table has systems and processes in place to try to address that, so you have declarations, you have records of interest and I think that is well and true and something that needs to be taken account of. I suppose, as a clinician, I sit back and look at all that and think, well, ultimately what you are about is empowering people. So if you have, in governing body meetings particularly, 20 people sitting around a table, it is about every single individual person being open and welcome to challenge.
John Morton: I think it has not been necessarily the problem that people anticipated. I think the process is working well. I think our governing body are very sensitive to conflicts of interest, so we are asked every month if there are any new conflicts to declare. At every governing body meeting people are asked to declare any conflicts and people leave the meetings when it is appropriate. There was a high level of sensitivity and I think it is being well managed and we have systems, which do not include GPs, to make decisions about services.
Leon Douglas: I would reflect what John said, that our conflict of interest process extends to everyone who gets involved, pretty much. It is the start and finish of every even reasonably formal forum, so it is well embedded in the organisation. I do think it is quite a disempowering problem and the key challenging nugget that remains is the conflict between the GP provider role and the commissioner moving an out of hospital agenda. I think it is the single biggest barrier to us being able to move on that front.
James Clarke: Possibly one way to address that might be to look towards a wider degree of openness in terms of the disclosures that are required and possibly have a written declaration that needs to be updated say, every month. If you look at local authorities as an example of what their members are asked to disclose and that applies to me, because I am a member of a local authority, the level of interests that I have to disclose is extensive and way beyond everything I have ever seen in the constitution of a CCG. One thing that a local authority does have, which I have not seen a CCG develop as yet, is a standards committee which pronounces upon the interests of certain members and gives them permission to participate and vote on a certain subject in certain meetings. That could be a further development that CCGs might want to adopt at some point in the future.
Leon Douglas: I can understand that, but it does not tackle the point of it being a disempowering element for people.
Hasan Chowhan: I suppose sometimes it is a little bit disappointing to hear that it is disempowering or people feel disempowered because, I think it is all about transparency and I do not know that locally we do feel like that. If it is a case of we are talking about clinical services and as long as you can appreciate or describe the benefit of that clinical service then I do not think you need to feel disempowered. That is probably a state of mind rather than an actual requirement and I think that will come through time, through some development work and again really just through peer challenging.
John Morton: I think the real conflict is not so much about the conflict of interest for the GPs, it is the conflict between the contracting and payment of primary care being detached from local health services. How can you have a discussion about a local health service if you cannot discuss primary care and, in particular, if a gap is created? The best example of this is a gap is created about who is going to pay for somebody to go in and do the flu vaccine for home bound patients and you have a conflict of interest because it looks like your organisation is going to have to pay for it, but it is not in your constitutional ability to do that. However, it affects patients at the end of the day, so you have to do it.
Victoria Vaughan: Moving to assurance – where CCGs assure NHS England that they are doing the right things.
Nicola King: Assurance is not my area…[However] it was really clear to us that if you think about a continuum with authorisation being the minimum safe to proceed bar, that in order to help the whole of the CCG community, all 211, continue to develop we needed to be able to describe what excellence looks like. So we were really clear that whatever happened in between had to be understood in the context of describing what great clinical commissioning looks like and that is the genesis of the Framework for Excellence in Clinical Commissioning. That essentially describes what the attributes of a fantastic CCG are insofar as we know it now, recognising that that is not where anyone would expect all CCGs to be and that most CCGs will demonstrate an aspect of excellence in some shape or form. That it is unlikely that any CCG would demonstrate all of the aspects in everything that they do, but that there is then a space in between and that is where the assurance framework conversations began to take place.
Jag Dhaliwal: I have a bit of a critical angle in terms of assurance. I think it would be fair to say in terms of the literature, the experience of quality, because what is assurance for, it is about quality, but evidence from other organisations – Toyota Total Production System is the example par excellence – demonstrates that assurance is not where the action is at. In fact, assurance can be damaging. This is really interesting because it is paradoxical… It is the assurance at each step in the process that is important. That is much more about culture. Culture is really quite difficult to structure and turn into a document where you can tick off various bits and pieces. I think because of maybe our anxiety, our feeling a bit scared around the quality; we have sought to put a structure in place around assurance that potentially could be quite damaging. It ends up turning CCGs into bureaucracies. Currently, the rest of the NHS struggles under this as well. It ends up feeding the beast rather than feeding the patient. That happened at Mid Staffs, which was a prime example. Great assurance reports, everything was ticketyboo in terms of the information going up, but there was a complete mismatch between what was happening on the ground and what was going up.
Victoria Vaughan: Assurance needs to take place, you agree with that?
Jag Dhaliwal: Only because NHS England has said assurance needs to take place. In fact, it does not. Literature evidence would demonstrate it does not. It is more about quality culture that is important.
Leon Douglas: I think you need to just take a step back. Who are you trying to assure and why? To me, I want to assure the community that I am serving that I am delivering high quality services. Frankly – no disrespect – I do not care what NHS England think. I do not care what Jeremy Hunt thinks, because ultimately they are too far removed from what is happening.
Moosa Patel: I would concur with both you guys, what you are saying. You are much closer to this than I am, but certainly the two CCGs that we are interacting with at the moment are often incredibly frustrated by their interactions with and the assurance routes to NHS England. Their view is that their primary assurance is to the populations they serve and their membership base. That is where it should be, but they are often frustrated certainly by the interaction with local area teams and also some of the national guidelines. One of them was talking recently about some guidance that has been issued nationally around the production of annual reports for clinical commissioning groups and my understanding is it is over a hundred pages in length. It just felt to both CCGs to be incredibly onerous and as if you are just jumping hoops for the sake of jumping hoops and, indeed, do you need that level of guidance for the production of an annual report? I somehow doubt it. Some of this is perhaps still about a new set of organisations finding their feet and hopefully these aspects will get better going forward.
Victoria Vaughan: How much time at the moment is being taken up by assurance, would you say, from a CCG level?
John Morton: The first set of quarter three assurance meetings were three hours each and the preparation would have taken maybe 24 hours for the assurance teams….I do not think the assurance system is going to be fit for purpose, but it is in a developmental phase. We have fed back to NHS England from the third quarter assurance process and we would expect it to become significantly lighter in terms of how we move forward. However, I believe that the best organisations for assuring local health services are clinical commissioning groups, because of their connectivity with the local system.
Nicola King: I hear your comments, John, about your experience and I have heard similar ones, but I have also heard other CCGs talking about how the process has been really helpful, very developmental, very positive, it has been an engaging conversation, it has helped them look at things that they need to look at. So there is something about how we model the best of those conversations and ensure that every CCG has the best experience of that. I think we all agree with the purpose and the principles around it and there is something about what do we need to do to make that real. I think we know that there is an issue.
Moosa Patel: The last word
The function of good corporate governance is to ‘ensure that an organisation fulfils its overall purpose, achieves its intended outcomes for citizens or service users, and operates in an effective, efficient and ethical manner’. (Good Governance Standards for Public Services, Office of Public Management and Chartered Institute of Public Finance & Accountancy 2004). This is a helpful lens through which to observe corporate governance within CCGs.
At Capsticks, through our work with CCGs in the past twelve months, we have been impressed by the excellent progress they have made. The underlying principles of good corporate governance- accountability; transparency; probity; and focus on the sustainable success of an entity over the longer term – have been quite clearly evident.
In all cases, the Governing Body has played a critical role in shaping and exemplifying an organisational culture that is open, accountable and puts patients first.
Equally, we would expect that organisations that have formally been operating for just over a year, to have areas for development and CCGs are no different in that regard. But they have a strong platform upon which to build and that certainly bodes well for the future.