Since the machinery of CCG authorisation was given the go-ahead in April 2012, there has been much activity by the NHS Commissioning Board (NHSCB) and the Department of Health (DH) to develop and publish supporting advice and guidance to underpin the establishment of fully functioning CCGs by early 2013. Thoreya Swage gives an update.
Functions of CCGs
To begin the process, the DH published a document called The Functions of Clinical Commissioning Groups. It is a summary of the responsibilities of CCGs updated to reflect the final version of the Health and Social Care Act 2012 and identifies the key statutory duties and statutory powers that CCGs have in order to develop as commissioning bodies.
The areas covered include:
responsibilities as commissioners
development and monitoring of services
duties applying to public bodies and of co-operation.
The document highlights the difference between the duties that CCGs are legally responsible for (ie statutory duties) and the legal powers that they can use to help them perform their duties, such as how far the CCGs perform the functions themselves or with other partners, eg with local authorities, commissioning support services and other CCGs.
Commissioning primary care services
Around £12.6 billion (excluding drug costs and some locally enhanced services) is spent on primary care services (general medical and general dental services, as well as community pharmacy and high street optometrists).
Although CCGs are responsible for commissioning acute mental health and community services for their local populations, it would create a conflict of interest if they were to commission primary care as well. Therefore it is the responsibility of the local team of the NHSCB to take on this function. The NHSCB, however, needs to work closely with CCGs to ensure that primary care services are aligned with and complement other NHS care on a local level. This means that the planning, securing and monitoring of primary care services by the local NHSCB team should take into account the local CCG commissioning plans, Joint Strategic Needs Assessment, Joint Health and Wellbeing Strategies and the Pharmaceutical Needs Assessment. CCGs also have a statutory responsibility to support the NHSCB in enhancing local primary care services.
The local NHSCB has other responsibilities which have been transferred from the Primary Care Trusts and can impact on CCGs, including:
managing the exits and entries of local performers list
managing the entry and exits of pharmacy services
managing individual performance issues of the primary care contractors (GPs, dentists, pharmacist and optometrists)
contracts for disposing of clinical waste
ensuring that occupational health services for primary care contractors and their staff are commissioned
distributing forms, eg sight test forms and prescriptions
managing GP premises reimbursement (GP IT functions will be delegated to CCGs to enable greater integration with other systems).
The provision of locums and other temporary staff and bulk purchasing of equipment and services (other than clinical waste) is the responsibility of the primary care providers themselves.
The management of the payment services is currently under discussion. The payment of all dental and pharmaceutical services will be undertaken by the NHS Business Services Authority and work is underway to draw up a national specification for primary care ophthalmic payments. The payment of GP services, ie patient registration and other practice payments, has yet to be determined.
The local NHSCB will establish a small core group of clinical professionals called Local Professional Networks (LPNs) to secure dental, pharmaceutical and optical services and provide expert advice on developing these services in their wider context, facilitate patient and public engagement in this arena and be a resource for other clinical networks such as clinical senates.
The local representative bodies (local medical, dental, pharmaceutical and optical committees) will remain and continue to play an important role in capturing the contractors’ perspectives on service and other issues.
CCG model constitution framework
In April 2012, the NHSCB produced a model constitution framework for CCGs to use as part of the authorisation process.
As statutory bodies, CCGs are required to draw up a constitution to describe their role and functions to demonstrate how they will meet their duty to commission services for their local populations. The constitution outlines the principles, rules and procedures determined by the CCG which govern the way it works ensuring probity, accountability and transparency of operating and that the interests of patients and the public are the focus of the organisation.
The constitution describes the main characteristics of the CCG, ie name, area covered, values and aims, as well as the functions the group is required to carry out, the decision-making structure and roles and responsibilities. There is also a procedure for conflicts of interest to be declared and for managing them appropriately.
The constitution not only applies to members of the CCG board and employees but also to the constituent practices and anyone else working on behalf of the CCG. It is a document that should be accessible to the public.
Roles of CCG members
Although CCGs have the flexibility to design their own governing bodies, the Health and Social Care Act 2012 and supporting regulations The National Health Service (Clinical Commissioning Groups) Regulations 2012 have described the minimum requirements, including concerning membership.
Each member of the governing body is required to have a core set of skills, competencies and attributes as well as bringing specific skills as individuals to the table. Each individual should bring the following attributes, skills and personal experiences to the CCG governing body. An individual must:
understand and demonstrate delivery of good health outcomes, address health inequalities and ensure best value for taxpayers’ money
understand and commit to effective governance and accountability for public money
uphold the NHS Constitution and commit to the Nolan Principles of Public Life
ensure that the CCG remains “in tune” with its constituent practices and commits to clinical commissioning and the interests of the wider health service
demonstrate leadership and commit to wider health and social care integration
possess the ability to question information, understand complex issues, influence others, take an objective viewpoint and communicate well
understand what good governance means and have an appreciation of the wider political, social and economic picture around health
have previous experience of working in a “collective decision-making group” and a track record of promoting improvement for patients.
Each CCG is required to have a Chair, an Accountable Officer, a Chief Finance Officer, secondary care specialist, nurse, a lay member with a role of overseeing main aspects of governance such as audit and another lay member with a patient and public engagement role.
The Chair can be any member of the CCG governing body except for the Accountable Officer, Chief Finance Officer, secondary care specialist, nurse or lay member with a governance role. The Chair may also be the Clinical Leader.
The Chair is responsible for leading the CCG, including influencing clinical and organisational change to achieve the commissioning aims, building the governing body, ensuring that the statutory duties are fulfilled and supporting the Accountable Officer. An essential attribute is to ensure appropriate patient and public engagement and have an unbiased view on possible conflicts of interest within the CCG.
The Clinical Leader is the person recognised by the CCG to be the clinical representative for the whole group and may also be the Chair or Accountable Officer of the CCG. The Clinical Leader will attend the NHS Commissioning Assembly.
The Accountable Officer is proposed by the CCG and appointed by the NHS Commissioning Board. The Accountable Officer could be a GP supported by an expert senior manager or a manager with Clinical Leader support. This role requires a broad understanding and experience of policy and strategy of health and social care and can build an expert team. As Accountable Officer, this role is required to ensure that the functions of the CCG are discharged effectively, securing best value in outcomes and use of public money.
Chief Finance Officer
The Chief Finance Officer must have an accountancy qualification and have adequate experience to lead the financial management of the CCG. In addition to ensuring the financial compliance of the CCG, the Chief Finance Officer may also carry out financial strategy and governance.
General Practitioner or other healthcare professional acting on behalf of member practices
This key role involves the contribution of the views of individual member practices to the CCG whilst putting aside specific single practice issues, having a greater knowledge of their locality and taking a balanced perspective between clinical and management areas.
Lay member with a governance role
This member needs to bring an external view to the CCG and has the responsibility of overseeing the main elements of governance including audit, remuneration and managing conflicts of interest. This lay member can be the Deputy Chair but not the Chair of the CCG.
Lay member with a role in ensuring patient and public engagement
This role brings in expertise in engaging the local community to the CCG. A key aspect of this role is to forge links with local HealthWatch and to ensure that arrangements are in place to secure patient and public involvement and feedback. This lay member could fulfil the role of Chair or Deputy Chair of the CCG.
Secondary care doctor
Essentially this person must be a consultant of at least 10 years’ standing with a good understanding of how care is delivered in the hospital setting. He or she will ideally have experience in working across primary and secondary care, developing and using patient pathways and have knowledge of service redesign.
This role must be undertaken by a registered nurse who has experience and knowledge of working at a strategic level and an understanding of working across primary and secondary care, patient pathways and service redesign.
Code of conduct
To ensure probity and to support CCGs in demonstrating that conflicts of interest are managed appropriately, the NHSCB published a document called Code of Conduct: Managing Conflicts of Interest where GP practices are potential providers of CCG-commissioned services.
CCGs are permitted to commission other services from their constituent practices. The CCG would, however, be required to demonstrate that the services commissioned from a practice go beyond what is normally delivered in primary care and meet the needs of the local population.
An appropriate procurement approach also needs to be employed. Essentially any GP who sits on a CCG governing or sub-committee who has a material interest in a specific procurement proposal is required to declare this interest and should not have a vote, or is excluded from the relevant part of the meeting. Advice on which would be the best route would be obtained from the Commissioning Support Services.
CCGs are required to publish details of all their contracts including the value once they have been agreed.
Public Health guidance to CCGs
The Health and Social Care Act 2012 requires each CCG to obtain advice to enable it to ensure the effective “prevention, diagnosis and treatment of illness” and to protect or improve public health.
From April 2013, the public health function will transfer from Primary Care Trusts to local authorities. Local authorities, therefore, have a statutory duty to provide this advice and expertise to CCGs.
The range of public health advice that is proposed to be provided to CCGs includes needs assessment, reviewing the provision of services, guidance on determining priorities, support for procurement of services and monitoring and evaluating care.
Local authorities and CCGs can also agree other public health service provision over and above what has been proposed. However, this would need to be discussed locally.
Securing Excellence in Commissioning Primary Care, NHS Commissioning Board, June 2012
Model Constitution Framework for Clinical Commissioning Groups, NHS Commissioning Board, April 2012
Code of Conduct: Managing Conflicts of Interest where GP Practices are Potential Providers of CCG-commissioned Services, NHS Commissioning Board, July 2012
Other resources for CCGs are available on the NHSCB website