There are several issues that I think all emerging Clinical Commissioning Groups (CCGs) need to start considering in detail with their PCT Clusters and with the support of their SHA. I want to use this update just to outline these issues. Many of you will already be considering these in detail, however I think it’s important that we start to debate these.
The first is emerging CCG size. Size so far is very variable, ranging from as little as a few thousand to many hundreds of thousands. The shapes of emerging CCGs have been built up from the bottom and these patterns reflect local choices. We now need to test these models to see if they are robust to deliver high quality commissioning. I would be surprised if this were not one of the early aspects of authorisation, quite simply explaining why the size of your consortia is best suited to the task you face.
Over the past few months work has been done on building a model that will allow developing CCGs to look at the costs of the essential features that they will require e.g.; Governing Body and local support services. These are the costs that each emerging CCG will need to bear. This tool will be released to emerging CCGs very shortly. It will then allow you all to see how much are fixed costs and what you will have left for commissioning support services. We know that the running costs allowance is likely, following the Pause, to be in the Region of £20-25 per head and from this you can get a very clear view of the amount each group will have for Commissioning Support.
Recently I heard Claire Gerada speak and she was advocating the need for larger sized CCGs to develop through smaller CCGs coming together under the banner of Federations. This is a model that could provide an excellent organisational infrastructure whilst maintaining local autonomy. Some areas such as Cumbria already work with this model of a central umbrella CCG encompassing localities that are semi- autonomous.
I’m not advocating any particular size, as local issues need to be considered; however I am re-framing the issue and saying that it makes sense to start by considering larger organisations and then to test out the strengths and weaknesses of this model for you. Issues such as geography, relationships with Health and Well Being Boards, (HWBs), and running costs all need to be taken into consideration. In the East of England we will shortly issue a brief list of issues, building on those above that we feel you need to take into consideration. These are local choices and as part of that choice the hypothesis of larger size being more efficient needs to be fully tested.
This leads me into the next issue of Commissioning Support. From the comments above you will see that soon you will be able to have a very clear sense of the funding that will be available to you for Commissioning Support. This is one piece of the jigsaw that will be needed to determine the final picture for each area. However funding is not the only part of the complex issue and one issue that needs to be considered is how we leverage commissioning improvement. PCTs achieved a variable level of commissioning effectiveness. We have recognised that this was not good enough; hence one of the reasons for the current changes; to improve the effectiveness of commissioning and thus, improve outcomes. It therefore follows that if we re-provide the same support, we are likely to obtain the same results. A couple of the traps in decision-making are those of continuing with the status quo and also a trap known as the anchoring trap. (Harvard Business Review has an excellent series of articles on decision-making). The status quo trap means that we are likely to continue with the existing set up, as consideration of change is too risky compared to the “comfort” of the status quo. Anchoring means that all too often we focus on a number; 7 or 6 or 3 and once the number is mentioned it sticks. If we are not careful we may fall foul of both of these traps; anchoring on PCT cluster numbers.
Large support organisations are likely to more cost effective; however arguments raised against size are that they will not be responsive and also that we don’t have a great track record of delivering these in certain areas of the NHS. The first point requires further assessment as what is it that causes concern about size and responsiveness? This is a nut that many businesses have cracked; customisation, yet provision at scale. The interface between the customer and the provider is the crucial aspect and many have solved this.
Are you really bothered about how the provider delivers the service provided they deliver your outcomes? Indeed I would probably argue that too often we have over specified how providers must deliver for us rather than setting a range of outcomes and letting the provider determine delivery mechanisms. One example that comes to mind, that of contracting; is this something we can really replicate with the full range of skills required, at a very local level; what has history taught us?
It’s difficult to leave this issue without a personal view. I’ve thought long about this and I’m clear in my mind, that if I were running an emerging CCG I would be seeking to develop a very “light” local CCG base. I would be looking for provision at scale to ensure I had access the technical skills that are needed and I’d be looking for a very customer centric approach
What ever your views? This is something that requires CCG, PCT and SHA consideration now.
The final area I want to tackle is that of co-terminosity between emerging CCGs and Health and Well Being Boards. This is an issue for us in the East of England in that we have 5 emerging CCGs looking to straddle HWBs boundaries. I’m sure it’s an issue elsewhere. We’ve asked all emerging CCGs to describe the reasons for this and largely, but not exclusively, they are around acute commissioning. The flip side of this is the argument that for too long we have focussed on acute and now we really need to start looking holistically at health and social care as a whole; and this means that emerging CCGs do need to have the same boundaries as HWBs. This position is being supported by many groups such as the King’s Fund. So how do we approach this? We are asking emerging CCGs to meet with HWBs to discuss these issue and if they need support will help facilitate these debates so that we reach an agreement over the next couple of months. These discussion need to start now so that by the end of the summer we have agreed positions on these issues. There is no single answer; it will depend upon local issues; however in the East we will also provide a framework of issues to consider in this debate.
In the text above I’ve covered three quite difficult issues; however now is the time that we need to consider these in depth. Many of you are well down that road; and although this is not a race these are important issues that need to be resolved early on in your local discussions.