Friday, 11 November 2011


Mick Jagger may have felt that time was on his side, but many of us don't.  April 2013 looms large, with only 507 sleeps (it is nearly Christmas...) until CCGs must be authorised in full or partial form.   There remains significant variability in CCG progress and, whatever one feels about the reforms, this variability is unlikely to benefit patients.  So what are the main issues facing CCGs at the moment?  After a lengthy brainstorming session (alone) these are my thoughts, focusing on authorisation:  No doubt there are many more and they will vary - please let me know what I've missed.

Having a clear vision
The need for clarity increases, and having a clear vision to drive progress is vital.  Whilst we can't always wait for detail there is an increasing need as authorisation approaches, as the focus needs to be on patient care and services rather than structures.

Developing real and meaningful patient engagement
There is a definite desire to improve this, and many ideas re: doing so.  Avoiding token representation on committees, enabling genuine challenge from patients, ensuring a cross section of views - this will be a key test for clinical commissioning in the future and one we should be judged by.

Working together with clear roles
We must ensure we work together constructively and have clear roles.  CCGs should be clinically led, but with support and challenge from managers.  Relationships are vital, and the culture and behaviour of CCGs will determine success or failure.

Governance structures
CCGs have significant responsibility, and with that a duty to have strong Governance systems and support.  It's there to challenge and protect.  Separating governance and management is difficult, and will need much input from lay members.  Setting up audit committees, establishing clear lines of delegation - all important but time-consuming and must not detract us from the vision we set and the need to focus on patients.  Work with others to agree structures, taking advice from existing non executive directors and Chairs.  We have many of the responsibilities of PCTs but need to have a different feel and culture.

Understanding and developing partnerships
Identify what the potential benefits are for collaborative work, and accept the need to 'let go' of some roles which may be better done jointly with a Commissioning Support Organisation or Local Authority.  Getting these arrangements right will be vital if we are to encourage wider views, better integration and efficiency with commissioning resources.  There are many competing interests but none should override what is best for the services or patients.  Provider partnerships are essential if we are to achieve integration and enable transparent governance mechanisms.

Establishing an effective Health and Wellbeing Board
These have tremendous potential, but will be judged on outcomes not words.  We have reviewed key issues in Nottinghamshire such as dementia, alcohol and substance misuse and childhood interventions.  We need to ensure the time given and potential for change is not wasted, and that there is a clear strategy and benefit from these boards.

Running Costs
There is still significant debate regarding size and running costs.  April 2013 is a deadline which does not allow for a lot of further reconfigurations. 

Setting Priorities
There seems to be an endless stream of improvement opportunities.  Establish which are most important to patients and for large scale benefit.  Some issues may be quality related, and having a firm understanding of these issues will be crucial.  QIPP is important if we are to have resources to improve services, but if we achieve financial balance at the expense of patient care we will have failed.

Transition arrangements
Establishing CCGs, PCT capacity reduction, newly clustered PCTs and SHAs and a new NHSCB represent significant challenges to the system.  We need to ensure quality and safety are the main focus during this period, and that we ensure there are robust systems to manage this.  Clusters will, rightly, want to have confidence in the arrangements set up and they will undoubtedly evolve over time.  We might resemble PCTs during the transition, but for a reason.

Valuing Clinical time
Balancing the roles of clinician and commissioner is difficult both in terms of time and duty.  Good governance and challenge will protect against this, but the interests of patients must be paramount.  Many GPs will be working harder to maintain patient continuity and fulfil their CCG role.  Organisational and personal development needs will be significant.  Working together with managers and as a GP community is vital if we are to succeed.

(For those of you who are curious, it's 43 sleeps until Christmas.)

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