Commissioning England Wales

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Quick guide to commissioning

Why do I need to know about commissioning?

The Health and Social Care Act (HSCA) radically changed how care is commissioned.

Primary care trusts and strategic health authorities were abolished and in their place clinical commissioning groups (CCGs) formed from GP practices now commission secondary care.

The HSCA created NHS England (formerly the NHS Commissioning Board), an independent board to oversee the running of the NHS and commissioning primary care and some specialist services.

For the commissioning structures to deliver on their promise of truly clinician-led commissioning, it is vital that all GPs get involved in their CCG, hold their CCG to account and involve colleagues from across secondary care and public health in the commissioning process.

 

30 second guide to commissioning

What is commissioning?

Commissioning is the effective planning and delivery of healthcare to meet the needs of the population.

How has commissioning changed?

Since the Health and Social Care Act, GP practices formed clinical commissioning groups (CCGs) which take responsibility for the commissioning budget.

Why did the government want to change commissioning in the NHS?

The government wanted commissioning to be clinician-led, locally focused and to promote patient choice.

What are the new structures?

  • NHS England (formerly The NHS Commissioning Board)
  • Clinical Commissioning Groups (CCGs)
  • Commissioning support units
  • Health and wellbeing boards
  • Clinical networks
  • Clinical senates
  • HealthWatch

What is co-commissioning?

Read about the changes to the way primary medical care is commissioned and contracted in our guide to co-commissioning.

What are our concerns?

Conflict of interest, genuine clinician-led commissioning, timescales, financial pressures, complexity.

 

  • Clinical commissioning groups (CCGs)

    England's 211 clinical commissioning groups (CCGs) will take over from primary care trusts and be responsible for £65bn of the £95bn NHS commissioning budget.

    They will plan and commission hospital care and community and mental health services.

    All GP practices have to be members of a CCG, and every CCG board will include at least one hospital doctor, nurse and member of the public.

    To become an NHS statutory body, a CCG has to be 'authorised' and to get authorisation they have to have a constitution.

    Find out more about what a CCG constitution should include

  • Commissioning support units

    GPs and other clinicians involved in clinical commissioning groups (CCGs) will need support to commission effectively.

    Commissioning support encompasses a range of functions, from transactional services such as payroll and IT services, to equipping CCGs with the complex population level data required to inform commissioning decisions.

    NHS England (formerly the NHS Commissioning Board) is temporarily hosting the twenty-three commissioning support units (CSUs) that have emerged from (now abolished) PCT clusters.

    It is proposed that all these services will move to freestanding models, for example by forming social enterprises or to partner with other organisations, including the private sector, by April 2016 at the latest.

    CCGs may also choose to host their own, internal support services or contract from private or third sector organisations.

  • Health and wellbeing boards

    Each council will have a health and well-being board that will bring together leaders from the health and social care system to improve the health and well-being of their populations and reduce health inequalities.

    The boards aim to influence commissioning and strengthen local healthcare democracy, and will develop joint strategic needs assessments. These should cover healthcare, social care and public health, and address other services that impact on health and well-being.

      

    What the BMA thinks

    The BMA welcomes close working between local authorities and CCGs. A strong dialogue between policy makers and commissioners across health and social care will result in intelligently structured and efficient services.

     

    • Responsive and streamlined structures

    The Commons Health Select Committee raised serious concerns that the proposals to establish health and wellbeing boards were unnecessarily bureaucratic. The committee recommended in a report in April 2011 that the proposals should be dropped and that the production of the JSNA and the JHWS should be the joint responsibility of local authorities, CCGs and Public Health England.

    The BMA shares the concern that the proposals could potentially result in a needless layer of bureaucracy, but believes that a specified forum for discussion could streamline the process of collaboration between stakeholders.

    It is important that the boards encourage true partnership between local authorities and CCGs. To this end, the BMA recommends that health and wellbeing boards should be small, functional and responsible bodies.

     

    • Partnership working

    CCGs need to participate fully in the workings of the board and be prepared to develop mutually supportive relationships. These relationships are particularly important given the scrutiny role that health and wellbeing boards will have in overseeing the commissioning plans of the CCG.

    Further detail is needed relating to the CCG's requirement to consult the health and wellbeing board. We would urge flexibility in this process, in order to prevent overburdening the CCG with different measurements of quality or performance.

    In order to guard against unnecessary delays and conflict, CCGs should be careful to involve the health and wellbeing board from the start of the commissioning process so that issues can be dealt with along the way.

    CCGs should also be careful that the scrutiny function undertaken by health and wellbeing boards does not duplicate the role of the CCG's own governance committee. The governance committee of the CCG will have responsibility for ensuring the probity of the financial and commissioning decision making of the CCG.

    This audit role differs from that of the health and wellbeing board, which should focus on the commissioning strategy adopted by the CCG. The value of health and wellbeing boards will be their attention to the integration of health and social care and public health aspects of a CCG's commissioning plans.

    It is important that the advantages of clinician-led commissioning - placing doctors and other health professionals at the heart of the decision-making process – are not stifled by excessive interference in the clinical decisions a CCG takes.

    The health and wellbeing board will most usefully focus on promoting collaborative working, bringing to the commissioning process appropriate and valuable input from social care and public health.

    Local authorities have been given the freedom to determine how many local authority representatives sit on the board. We would urge an equal balance between local authority and CCG representatives, in order to avoid politicisation of the functioning of the board, and to foster balanced and collaborative working.

     

    • The role of Local Medical Committees

    The BMA has serious concerns that the membership of health and wellbeing boards does not include representatives of local medical committees (LMCs) and we have raised this with the government and in briefings with MPs and peers.

    LMCs are the only statutory representatives of GPs and perform a crucial role in negotiations between local authorities and the local profession. LMCs represent the views of the local profession independently from the local commissioning groups and will be central to ensuring that CCGs have the support and engagement of constituent practices.

    If an LMC has not been involved in the process thus far, they should actively seek engagement with the local authority.

     

    • Geography

    Health and wellbeing boards are aligned with each upper tier local authority. This should pose no problems where a CCG’s boundaries are co-terminus with those of the local authority (mainly in the case of unitary local authorities).

    In the case of county local authorities, the boundaries of which may encompass a number of CCGs, consideration should be given as to how the CCGs are represented on the health and wellbeing board.

    One person could be elected to represent two or more CCGs in an area, to avoid unnecessarily large membership of the health and wellbeing board.

    If this is the case, then it is vital that effort is made to foster strong relationships between the CCGs and this individual, and also between the CCGs and the health and wellbeing board itself.

    See the new health and wellbeing board directory (King's Fund)

     

    • The transition period

    The transition period until 2013 will require a certain degree of flexibility as the structures involved establish themselves and CCGs seek authorisation. CCG representatives on the health and wellbeing board need to be mindful of the potential for conflict of interest as the board participates in the authorisation process.

    CCG representatives should absent themselves from discussions relating to the readiness and ability of their own CCG or other CCGs in the area to take on commissioning responsibility.

  • HealthWatch

    National patient champion, Healthwatch England, will aim to ensure that the voices of service users are heard by the health secretary, the Care Quality Commission (CQC), Monitor and NHS England.

    Healthwatch will be commissioned by the local authority and held to account by the local authority's overview and scrutiny committee.

    Local authorities have established local Healthwatch organisations, which replace local involvement networks.

    They will inspect services, influence how they are set up and commissioned, provide information, advice and support about them, and pass information and recommendations to Healthwatch England and the CQC.

  • NHS England

    NHS England is an independent board accountable to the health secretary for the running of the NHS. It took on its full statutory responsibilities on 1 April 2013, after existing in shadow form since October 2012.

    NHS England will have a national, regional and local structure and will be responsible, among other things, for commissioning primary care and specialised services. It has authorised all 211 clinical commissioning groups (CCGs) - although only 43 were fully authorised - will oversee their development and hold them to account.

    The Government published its mandate to the board on 13 November 2012. It sets out the health service's priorities for the next 2 years.

    The BMA responded to the consultation on the mandate and were encouraged that many of our views were taken on board. However, its success will depend on how it is translated in practice. 

     

    Single operating model

    Underpinning the new arrangements is a single operating model for primary care for area teams. 

    Until now, a number of policies were locally developed by PCTs and their predecessors. This operating model aims to ensure that contractors are treated transparently and consistently across England. NHS England has commissioned NHS Primary Care Commissioning to develop a suite of policies to ensure area teams do not develop policies that are not consistent with national arrangements.

     

    NHS mandate

    Read more about the NHS mandate and how we responded to the consultation

    The NHS mandate

    BMA summary of the NHS mandate

    BMA response to the NHS draft mandate

    Read our news story - 'Implementation key to NHS mandate success'

  • NHS England sectors and Local Area Teams

     

    Sectors

    There are four regional NHS England sectors as follows:

    • North of England
    • Midlands and East of England
    • South of England
    • London

     

    Local area teams

    NHS England has 27 local offices, or local area teams (LATs), with among other things, responsibility for primary care contract management.

  • Clinical networks and senates

    Clinical networks

    Clinical networks are condition or service area specific.

    Four strategic clinical networks (SCNs) have been confirmed for 2013:

    1. Cancer;
    2. Cardiovascular disease (incorporating cardiac, stroke, diabetes and renal disease);
    3. Maternity and children; and
    4. Mental health, dementia and neurological conditions.

    SCNs will be established for up to five years in the first instance and NHS England (formerly the NHS Commissioning Board) can identify new conditions or patients groups that require a specific SCN in the future.

     

    Clinical senates

    Twelve new clinical senates across England now provide strategic clinical advice and leadership to CCGs, Health and Wellbeing Boards and the NHS England on a geographical basis They are multi-professional and include patient representatives.

    Twelve corresponding support teams provide clinical and managerial support to the SCNs and clinical senates in the area. The teams are funded and hosted by NHS England.