Since the enforcement of the Health and Social Care Act in March 2012, work has begun in earnest to ensure that the new Clinical Commissioning Groups (CCGs) are fit and capable of performing their commissioning responsibilities by 1 April 2013. Thoreya Swage details the authorisation process.

In September 2011, prior to the establishment of the NHS Commissioning Board (NHSCB), the Department of Health published its guidance Developing Commissioning Groups; Towards Authorisation, setting out the key principles that form the basis of the criteria against which CCGs will be authorised. These are outlined as the following six domains of capability.

  • A firm, clinical and multi-professional emphasis which brings extra value to the commissioning of services.

  • The meaningful involvement of patients, the public and local communities.

  • Clear and achievable plans which deliver: the Quality, Innovation, Productivity and Prevention (QIPP) requirements and the financial challenge up to 2014–15; and identified health outcomes and evidence of working with the local Health and Wellbeing Boards (eg Joint Strategic Needs Assessments (JSNA) and Joint Health and Wellbeing Strategies (JHWS)).

  • Formal and credible constitutional and governance arrangements, including the capacity for proper financial control and effective commissioning of care.

  • Clear, collaborative commissioning arrangements with other CCGs, local authorities and the NHSCB, in addition to securing appropriate external support for commissioning.

  • Leaders who are able to make a difference both individually and collectively.

The guidance was further developed in April 2012 with the publication of the NHSCB’s document Clinical Commissioning Group Authorisation: Draft Guide for Applicants. This details the process that CCGs are required to go through, including the steps to be undertaken, criteria, thresholds and evidence for authorisation. It also sets out the timetable for the four waves of applications in July, September, October and November of this year. Applications are permitted no later than November 2012 in order to allow enough time for CCGs to undertake further work on their development following the authorisation decision in January 2013.

Although draft guidance and subject to secondary legislation, most of the information contained within it is not expected to change substantially.

Phases of authorisation

The NHSCB defines three distinct phases for CCGs to go through in order to become authorised.

  • Pre-application.

  • Application.

  • Assessment by the NHSCB.

Phase 1: pre-application

The first phase began in 2011 with the self-assessment diagnostic to assess the level of developmental needs of the CCGs, together with delegation of the commissioning budget from the Primary Care Trusts (PCTs). This was supported by a national leadership development initiative run by the National Leadership Council.

The process now concentrates on the final configuration of the CCG and full authorisation.

A month prior to the application date for the wave of authorisation to be undertaken, performance data and population health profiles will be sent to the CCG for consideration. This will include information such as:

  • geography and relationships with other agencies, eg local authorities, as well as the relationship between the registered (practice) and resident (including those not registered with a CCG practice) populations

  • population profile, including age/sex/deprivation indices

  • outcomes data at population level

  • activity and outcomes data by the main provider

  • performance and financial data.

The NHSCB assessor team will use the CCG profiles to appraise the challenges faced by each CCG, and this forms part of the authorisation process. In turn, CCGs will gather the types of evidence required for submission, examples of which are shown in the table below.

Evidence

Examples of evidence

Governance arrangements

  • Identified vision.

  • Clear CCG configuration.

  • CCG constitution signed off by member practices.

  • Accountability arrangements clarified between member practices and the CCG.

  • Clear systems for reporting and monitoring patient safety issues.

  • Clear mechanism for safeguarding, reducing health inequalities and ensuring outcomes from healthcare.

  • Identified commissioning support.

  • Clear arrangements for working with the local office of the NHSCB.

Financial management

  • Clear arrangements for:

    • internal and external financial audit

    • schemes of delegation

    • counter fraud

    • cash flow, payroll, banking and fixed assets

    • risk sharing with other CCGs.

2012–13 healthcare contracts

  • 2012–13 contracts signed off with main providers.

  • Monitoring of the 2012–13 contracts.

  • Arrangements in place to negotiate, manage and monitor contracts from April 2013 onwards.

Structure of the CCG

  • Decision-making informed by clinical considerations.

  • Arrangements for secondary care doctor and nurse to be on CCG board.

  • Lead clinician identified for specific commissioning priority areas, and for safeguarding children and adults and the Mental Capacity Act 2007.

  • Chair of the CCG and Chief Finance Officer recruited in line with national guidance.

  • Promotion of research, education, training and innovation.

  • Establishment of complaints mechanism.

Plans for 2013–14

  • Clear commissioning intentions, including setting out of financial plan, QIPP requirements and JSNA.

  • Commissioning intentions to meet the NHS outcomes framework requirements.

  • Lead CCG commissioning arrangements established.

Joint working arrangements

  • Clear plans demonstrating joint working with other CCGs to meet QIPP requirements.

  • Clear plans for joint working with local authorities via the JHWS and Health and Wellbeing Boards.

Support providers

  • Agreed Service Level Agreements with support providers for communication, payroll and information services.

  • Clear accountability arrangements between the CCG and support providers.

  • Adequate in-house arrangements for managing commissioning support.

Multi-professional and Health and Wellbeing reports

  • Minutes of meetings to demonstrate involvement of healthcare professionals from other areas of care (ie community, secondary, learning disabilities and social care).

  • Evidence of collaboration between the CCG and shadow Health and Wellbeing Board, and discussions on JSNA and JHWS.

Governing body actions

  • Minutes of the CCG Board showing discussions covering clinical and quality issues, monitoring and acting on patient involvement and feedback, and patient safety reporting and concerns.

  • Systems in place to identify early failing services.

  • Compliance with public sector Equality Duty.

Draft JSNA and draft JHWS

  • Clear arrangements stating how public health advice would be provided to the CCGs.

  • Involvement of strategic partners and stakeholders, reduction of health inequalities and integrated commissioning.

Plan for organisational development

  • Demonstration of how the CCG will train and develop staff in key areas, eg safeguarding, managing commissioning support and continued leadership development.

  • Demonstration of how staff competencies will be developed.

Risk management

  • Arrangements in place to manage financial, clinical and corporate risk.

  • Assessment of risk to the delivery of QIPP.

Communications

  • Systems in place to engage and communicate with patients and the public, member practices and partner agencies.

Evidence from case studies

  • Examples of:

    • improvements in quality and productivity in services and innovation

    • member practices involved in decision-making

    • systems for monitoring and acting on patient feedback, including safety concerns

    • devolved responsibility for the commissioning budget and other delegated functions on the 2012–13 contracting round

    • engaging clinical professionals in service redesign

    • engaging other CCGs and a wide range of clinical professionals

    • CCG leadership development.

Phase 2: application

The information gathered in the pre-application phase will provide the core supporting evidence to the actual CCG application. The Chair of the CCG and proposed Accounting Officer are required to sign a declaration of compliance, which will be posted on the CCG’s website or where the public can access it, together with the supporting evidence.

Phase 3: assessment by the NHSCB

This phase includes:

  • a desktop assessment

  • a 360° stakeholder survey

  • case studies

  • a site visit.

Desktop assessment

This will be undertaken by the NHSCB team, which will have expertise in finance, commissioning, governance and clinical quality. Clarification may be sought by the NHSCB team and this information will be added to the application.

360° stakeholder survey

Approximately six weeks before each wave application, a 360° stakeholder web-based survey will be carried out by Ipsos MORI. Consulted stakeholders will include member practices, other CCGs, shadow Health and Wellbeing Boards, local authorities, shadow local HealthWatch and other patient groups, NHS providers, clinical networks and commissioning support services.

Stakeholders will be asked questions relating to the six domains of authorisation and, in addition, some stakeholders will be asked specific questions about the CCG in question.

Case studies

These provide an opportunity for CCGs to show that they can deliver improvements in health outcomes, service quality and productivity, access to care and reduction in health inequalities, as well as demonstrate learning and development.

The case studies need to cover the six domains of authorisation as well as specific service areas, including maternity care, mental health and learning disabilities, routine operations, emergency and urgent care, long-term conditions, continuing healthcare needs and end-of-life care.

Site visit

A site visit will take place once the CCG has had an opportunity to comment on the findings of the desktop assessment and 360o stakeholder survey. Conducting the visit will be a member of the NHSCB authorisation team, a clinical leader from a CCG in a different geographical area, a lay assessor and experts in finance and commissioning. Local authority or public health input may also be required depending on the results of the desktop review.

Authorisation outcomes

Only the NHSCB can legally make the decision on authorisation. Its decision will be final and there is no appeals process.

There are three possible outcomes of authorisation.

  • Full authorisation: the full range of duties and functions is taken on, and a development plan put into place for potential beyond authorisation.

  • Authorisation with conditions: conditional duties are taken on, eg how the CCG performs a function, or the function is carried out by the NHSCB or another CCG (conditions will be subject to review with a view to enabling the CCG to carry out its full responsibilities).

  • Shadow CCG established: CCGs are unable or unwilling to take on their commissioning functions, therefore the NHSCB ensures that alternative arrangements are made for the commissioning of healthcare for the relevant populations until the CCG becomes fully authorised. For CCGs unable to become established, the NHSCB will assign the relevant practices to other CCGs so that the populations are covered by a commissioning body.

Continuing assurance process

Once a CCG is authorised, a condition of its continued fitness to carry out its duties will be to participate in a continuing assurance process. This will be set out in the accountability framework to be published later this year.

CCG flexibilities

In April 2012, the Secretary of State for Health, Andrew Lansley, wrote a letter to the NHSCB making a number of points with respect to the authorisation process of CCGs.

He identifies the first and major objective as establishment of the new commissioning system as soon as possible, ensuring the transfer of responsibilities to CCGs that are able to carry them out. In order to do this, the authorisation process needs to be safe and effective, enabling the maximum number of CCGs to be authorised without conditions. For those CCGs that do require conditional authorisation, this is to be time-limited rather than continual.

The authorisation process should allow flexibility in the way in which CCGs carry out their commissioning duties and the organisations they can use to support them in this function; rather than the “top-down” approach of previous administrations, the intention is to permit “assumed liberty” of CCGs. To facilitate this, the NHSCB has been asked to develop “a transparent, rules-based system” to clarify how certain areas, such as pooling financial risk or dealing with poorly performing CCGs, are managed.

Last reviewed 21 May 2012