Last reviewed 15 September 2015
As result of the changing challenges posed by the ageing population and the growing number of people living with long-term conditions, Clinical Commissioning Groups (CCGs) have recently been required to take up new responsibilities. As such, they are now subject to a new assurance framework to ensure that they are delivering the best possible healthcare to the populations they serve. Dr Thoreya Swage looks at the new assurance process, the categories within which CCGs will be placed based on their performance, and the special measures that may be implemented should a CCG be found to be struggling.
In the year leading up to the enactment of the Health and Social Care Act 2012, prospective Clinical Commissioning Groups (CCGs) were required to undergo an authorisation process set by NHS England in order to function effectively as commissioning organisations.
Since April 2012, NHS England has conducted performance assessments of CCGs as part of its statutory duty to ensure that the capability and development of these bodies are maintained and continued. This is delivered through the CCG assurance framework.
The original CCG assurance framework covered six domains and asked the following questions:
Is the CCG commissioning high quality services, underpinned by a clinical approach?
Is the CCG actively engaging with their local patients and public?
Is the CCG ensuring that better outcomes are delivered for patients?
Are there robust governance arrangements within the CCG?
Is there partnership working between the CCG and other organisations?
Is there strong and robust leadership within the CCG?
These domains were designed to support discussions between NHS England and CCGs about their performance and developmental needs. Originally — in April 2013 — performance could not really be assessed owing to a lack of data on the newly created organisations.
Two years down the line, such data are now available and it is possible to measure how effectively CCGs are providing for their populations. In addition, as the NHS landscape has changed and the focus of the health service is now on integrated care, the challenges faced are greater, owing to an ageing population and an increasing number of people living with long-term conditions, coupled with a growing funding gap. This was recognised in a new strategy, the Five Year Forward View, published in October 2014.
Another change, and further indication of the shifting role of CCGS, is the added responsibility for commissioning primary care services delegated to CCGs by NHS England, which took place in April 2015.
The CCG Performance Framework (2015/16)
In line with the changing state of healthcare and the new challenges faced by CCGs, a new CCG Assurance Framework was therefore deemed necessary. It comprises the following five domains.
Leadership — this includes an assessment of the robustness of the leadership of the CCG and governance arrangements. This domain also assesses the effectiveness of the commissioning arrangements; whether there is support to ensure an efficient financial function to improve patient services; whether the CCG can achieve financial balance; and if the body can meet all its statutory duties.
Performance — this is an evaluation of the extent to which services are improved by the CCG and whether there is tangible quality improvement and better outcomes for patients. Measures arising from this domain form the CCG scorecard, which is then published as part of MyNHS on the NHS Choices website. The areas cover five population groups: people with long-term conditions, people with mental health conditions and learning disabilities, children and young people, frail older people, and the generally well. These patient outcomes are assessed against the NHS Outcomes Framework.
Management of finances — this involves the continuous monitoring of the financial management capability and performance of a CCG throughout the year, including the quality of its data and the tightness of its contractual management. If financial problems occur remedial action will be taken, which may include special measures.
Planning — this domain covers not only short term plans, such as annual operational plans, but also longer term strategic plans, for example the implementation of the priorities highlighted in the Five Year Forward View. It also considers progress towards digital processes, such as electronic discharge summaries, as part of the ambition to become a paperless organisation.
Managing the delegated functions — this is a new area of the assurance process for CCGs. From April 2015 CCGs have been assigned responsibility for managing the delegated function of commissioning primary care from NHS England.
The assurance process
CCGs are assessed using a risk-based approach which differentiates between CCGs performing well, those that are not doing so well and those somewhere in-between. The assurance process consists of a robust, structured and supportive framework for challenged performers, with a lighter touch for CCGs that are performing well.
The assurance process is continuous, so that emerging patterns of poor performance or potential areas of risk are identified early, using information obtained from various sources. Face-to-face assurance visits may also be required, the frequency of which will be agreed between NHS England and the CCG as determined by individual circumstances, the risks identified, and the response of the leadership of the CCG. CCGs operating in distressed economies will have a greater number of assurance assessments.
A statutory assurance report will be published by NHS England at the end of the year incorporating all the information derived from the assurance process. CCGs are also required to publish their individual assurance reports.
Sources of information
The information used to base the assessment of CCGs for the assurance process comes from national as well as local sources.
The CCG scorecard, which will be published on the NHS Choices website, forms a common information source covering core performance standards, finance, level of digital maturity, quality and outcomes.
In addition to the “single point” set of information provided by the CCG scorecard, other information produced on a continuous basis can be considered by NHS England to provide assurance that CCGs are delivering their statutory duties, including financial performance, and the adequacy of operational and longer term strategic plans to respond to performance pressures.
NHS England’s nationally commissioned 360 degree stakeholder annual survey will provide information to CCGs on improvements in quality and outcomes for patients. The survey will provide an indicator as to the maturity of relationships built by CCGs with their stakeholders and the level of organisational development within the CCGs themselves. The results of the survey are expected to be published by the individual CCGs and an overall picture produced by NHS England.
Local sources of information in the form of documents CCGs themselves produce in the public domain CCG board papers, internal and external audits and financial and strategic plans, may also be used. In addition, CCGs are required to publish an annual report on how they have discharged their statutory functions each year.
Other sources of information can come from local partners, including HealthWatch and Local Health and Wellbeing Boards, and organisations that have a local focus, such as the Care Quality Commission, NHS Trust Development Authority and Monitor reviews and reports.
CCGs will be placed in one of the following assurance categories.
Outstanding — this means that the CCG has provided assurance that it is performing well across the five domain areas. These CCGs will continue to have a “light touch” approach to assurance.
Good — this indicates that the CCG is well-led and has good organisational capability, or that the CCG is managing a higher level of risk effectively. The CCGs will be required to produce their own improvement plan and provide regular reports to NHS England on their progress.
Limited assurance, requires improvement — to be used in relation to CCGs exhibiting serious performance or financial challenges together with a high level of risk. CCGs within this category will be required to produce an improvement plan that is approved and monitored by NHS England. The plan should describe the consequences at each stage if it fails to deliver and NHS England may take intervening action if performance is poor. The plan also include sources of support to ensure delivery, such as through “buddying up” with a highly performing CCG.
Not Assured — In these circumstances, NHS England will undertake a detailed assessment with the CCG to determine the underlying causes and identify the remedial actions necessary in the improvement plan. If there is a lack of confidence in the CCG leadership, NHS England will work with the organisation to identify how new leadership can be established. If there is confidence in the leadership NHS England will specify a set of parameters within which the CCG can operate and maintain direct oversight until the CCG is observed to have improved.
Special measures are applied when a CCG is assessed as “not assured” or, in certain circumstances, “limited assurance”. A CCG will be put into special measures when there are grave concerns across the many responsibilities and functions it has.
Special measures establish a structured approach for a CCG to improve its performance or capability. This will have been set up following a situation where the CCG will have been assessed as failing to commission or plan services at the appropriate level for its population, or failing in its duties to achieve a financial balance, sustainability or value for money. Special measures will be a response to these issues that have persisted over a period of time.
It is anticipated that special measures are applied for a maximum of 12 months, after which a CCG is expected to exit this situation having achieved significant progress in its implementation plan.
The two main objectives for applying special measures are to:
prevent unacceptable risk to the patient safety and outcomes of the CCG’s population
improve standards through an action plan for sustainable improvement which is monitored regularly.
Triggers for special measures
Special measures may be triggered when there are concerns about financial or operational performance problems.
Operational performance — this is a situation that will have developed over time and the CCG will not have shown a clear understanding or grip of the situation, or that it has a robust quality plan and has utilised all levers possible to improve performance, or that the organisation has identified and is managing the risks arising from the challenges that are facing the CCG.
Financial performance — this is where the financial performance differs seriously from the plan, or there are significant unmitigated risks which the CCG forecasts in its plan. Weaknesses in financial controls, as demonstrated by internal and external audit, will also trigger special measures.
Special measures process
NHS England will, wherever possible, agree with the CCG that special measures are required and on the areas to be addressed and the timescale for delivery, together with the monitoring and review processes to be put in place. If there is no joint agreement NHS England will determine whether a CCG should enter special measures.
Once agreed, the following process applies.
The CCG is expected to communicate to local stakeholders via its website that it is in special measures, providing a brief description of the reasons for this, the plans for improvement, and timescales. Thereafter regular updates should be made on progress achieved.
Once agreed, and following an external review of the capacity, capability and governance of the CCG commissioned by NHS England, an improvement plan is required to be developed. The CCG is required to appoint an improvement director who will be accountable for delivery, together with Programme Management Office support. The improvement plan is drawn up at this point.
Intensive support in the form of expert input will be identified to facilitate the development and implementation of the improvement plan.
Regular reporting on progress will be made to NHS England.
The CCG will have deemed to be ready to exit special measures when significant progress is found to be made on the improvement plan, following regular monitoring by NHS England. If no significant improvement has occurred then changes in the management, structure or governance of the CCG may be required, in some instances, where another CCG or other body may take over some responsibilities.
Role of NHS England
NHS England has a key role in supporting the special measures process by; initiating a review of the capacity, capability and governance of the CCG; acting as source of advice; signing off the improvement plan; monitoring progress and removing the special measures regime.