Small may be beautiful, but “size matters”. That’s is the inescapable conclusion of the news that 1 in 7 CCGs (clinical commissioning groups, formerly known as GP consortia) are too small for authorisation. Health Service Journal reckons that 47 CCGs have fewer than 50,000 patients; some have as few as 5,000 – one is a single practice in Hertfordshire! But there are other reasons to be concerned about the CCG authorisation process, a draft pathway for which was released by David Nicholson as National Commissioning Board CEO designate last week.
No information means no intelligent commissioning
Our pathfinder CCG in Wandsworth is at least co-terminous with the borough and so covers all the practices and a user population of about 370,000. These commissioners need to be smart organisations. All CCGs will need lots of intelligent data generated by the constituent practices. To that end, the Future Forum remains in business and is about to start Phase 2 of its work, including a focus on “How information can be made to improve health, care and wellbeing”.
They may find this a bit frustrating when they realise that Government has already made what the HSJ calls “the frankly outrageous decision” that GP practices can opt out of the new GP data extraction scheme. This amounts to a huge potential disconnect between the grass roots and CCGs and public health just as momentum picks up down the pathway towards authorisation. David Nicholson should be twisting the arms of GPs about this, not acquiescing to their special pleading. Perhaps this shows the real power of private businesses, aka GP practices, in the new “Nicholson Health Service”.
Six domains to satisfy – watch out for Number 2
In the recently issued draft process for authorisation, there are “six domains” about which aspiring CCGs have to satisfy the National Commissioning Board they are competent. The second domain causes great concern in the light of recent events.
1. A strong clinical and professional focus which brings real added value
2. Meaningful engagement with patients, carers and their communities;
3. Clear and credible plans which continue to deliver the QIPP (quality, innovation, productivity and prevention) challenge within financial resources, in line with national outcome standards and local joint health and wellbeing strategies;
4. Proper constitutional and governance arrangements, with the capacity and capability to deliver all their duties and responsibilities including financial control as well as effectively commission all the services for which they are responsible;
5. Collaborative arrangements for commissioning with other CCGs, local authorities and the NHS Commissioning Board as well as the appropriate external commissioning support; and
6. Great leaders who individually and collectively can make a real difference
What happened at the end of July to effectively throttle local patient and public involvement on the alter of central control of the idol known as the “shared operating model”calls into question whether any CCG can satisfy this domain. But when one looks deeper, it becomes clear that David Nicholson doesn’t really expect them to do much. His draft says it is sufficient for Health and Well Being Boards and Local Healthwatch to be proxies for local people and their views. Real local voices and views from individuals and groups will not actually be part of the authorisation process. That is unjust. It makes a mockery of “nothing about me without me” and simply invites disengagement and distrust from the outset.
MAC was clear at the end of May when we wrote about the what the lay role should be through the whole authorisation process, not just one slice of it, including how to complain about what a CCG did once it was up and running. But this will not happen if the authorisation follows the mechanistic and excluding process contained in the draft:
There will be a role for shadow health and wellbeing boards in the authorisation process. Health and wellbeing boards will be crucial in bringing together all of the key local leaders for health and wellbeing such as local councillors, commissioners of adult social care, children’s services and public health, CCGs, and representatives of patients and public through local HealthWatch, to develop joint health and wellbeing strategies to inform both CCGs and councils’ commissioning plans. Health and wellbeing partners will be key in the 360 degree review, providing views on the CCG’s willingness and ability to be involved in partnership working and their relationship to the local population. This will influence the final judgement made by the NHS Commissioning Board [p 15]
GPs don’t seem keen anyway
To say that CCGs won’t work without all GPs on board, or at least not opposing, goes without saying. But will this happen by 2013 or even 2014? “Towards authorisation” may not be an obvious destination if the results of a recent IPSOS MORI poll for KPMG are correct. Top line results from a weighted sample of GPs across England interviewed during July suggest that patient and public involvement is way the down list of what they see as important. Only 15% identified it as a priority and the same percentage said they might “buy in” PPI work anyway without doing it themselves.
Financial expertise and pathway redesign were considered much more important. These are important, but what they fail to appreciate is that tough financial decisions – think decommissioning – and service redesign to achieve pathways, cannot succeed without patient and public involvement in shared decision making at every level of the NHS. The Future Forum report was crystal clear about this, as was Mr Lansley in his acceptance of its report. Someone should tell the GPs!
That aside, much more worrying for the Big Beast at the National Commissioning Board was that this snapshot found only one-quarter of GPs thought their CCG would be ready to take on full commissioning responsibility by April 2013 and maybe not even then.
Not a good place to be in
So where does that leave the prospects for authorisation? Not in a very good place we think. Pathfinders are rushing ahead, and in London taking over huge swathes of PCT responsibilities – virtually all of it in some areas – by this autumn. LINks are struggling in a parched climate to turn themselves into Local Health Watch and not exhaust the volunteers who are running them, while taking on huge new responsibilities with inadequate resourcing. PCT “clusters” are tightening their grip at the behest of the interests coming together in the NCB. CCGs of wildly varying sizes and capabilities are starting down an authorisation pathway many cannot finish. Lots of grass roots GPs just want the reforms to go away so they can wake up and “just be doctors again”. Their professional bodies are gearing up for a campaign to derail the Health and Social Care Bill when it re-enters Parliament in early September.
But the bad news is it isn’t going to go away, however many placards get waved. In a few months, we may well be looking back on this quietude of late summer 2011 with nostalgia as the cold blast of an arctic winter born of funding discontent, alienated professionals and confused and angry patients hits home. Who then would want to run a clinical commissioning group?
The Moore Adamson Craig Partnership supports user and public participation, trains lay representatives and develops responsive health, care and education organisations. We are ready to work with and support all those who want to make sense and a success of the new structures of patient and public engagement within the new arrangements for health and social care commissioning and providing. Feel free to contact us to discuss the opportunities.