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The implementation of the Health and Social Care Act 2012 commenced on 1st April 2013. Clinical commissioning groups (CCGs) are now the cornerstone of the new health system. Every GP practice in England is now part of a CCG. There are 211 CCGs, each commissioning care for an average of 226,000 people. CCGs commission the majority of health services, including emergency care, elective hospital care, maternity services and community and mental health services. In 2013/14 they were responsible for about 60% of the total NHS budget.
The structure of the new National Health Service
On 1 April 2013, the Health and Social Care Act 2012 came into force, bringing with it many new structures and arrangements for the NHS in England. Primary care trusts (PCTs) and strategic health authorities (SHAs) have been abolished.
NHS England (formerly the NHS Commissioning Board) and CCGs are now responsible for commissioning the vast majority of NHS services, with local authorities taking on new public health commissioning responsibilities. England's 211 CCGs have taken over from PCTs and become responsible for £65bn of the £95bn NHS commissioning budget. They 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 includes at least one hospital doctor, nurse and member of the public.
In general, CCGs are responsible for commissioning health services to meet all the reasonable requirements of patient care, with the exception of:
- Certain services commissioned directly by NHS England.
- Health improvement services commissioned by local authorities.
- Health protection and promotion services provided by Public Health England.
CCG commissioning includes:
- Urgent and emergency care (including A&E, ambulance services and NHS 111).
- Out-of-hours primary medical services (except where this responsibility has been retained by practices under the GP contract).
- Elective hospital care.
- Community health services (such as rehabilitation services, speech and language therapy, continence services, wheelchair services and home oxygen services) but not public health services (such as health visiting and family nursing).
- Other community-based services, including (where appropriate) services provided by GP practices that go beyond the scope of the GP contract.
- Rehabilitation services.
- Maternity and newborn services (excluding neonatal intensive care).
- Children's healthcare services (mental and physical health).
- Services for people with learning disabilities.
- Mental health services (including psychological therapies).
- NHS continuing healthcare.
- Infertility services.
Monitor is the sector regulator for healthcare, responsible for licensing healthcare providers, regulating prices for NHS services and addressing restrictions on competition that act against patients' interests. Monitor has assumed the role of system regulator for all NHS-funded services and all remaining NHS trusts are expected to become NHS foundation trusts within the next few years.
Effective commissioning is based on a continual assessment of the needs of a community and then designing, specifying and procuring services to meet these needs, within the resources available. Effective commissioning should be collaborative, community-focused, comprehensive and clinically led. Good healthcare commissioning is based on five key principles:
- Improving outcomes for patients and communities, prioritising demand over supply and encouraging innovation.
- Empowering patients through shared approaches to care, keeping patients fully informed and helping them to share their own care.
- Evidence-based practice in assessing needs, designing services and monitoring outcomes.
- Community mobilisation.
The commissioning cycle can be broken down into four stages:
- Step one: analyse and plan.
- Step two: design pathways.
- Step three: specify and procure.
- Step four: deliver and improve.
Essential roles for each clinical commissioning group
The commissioning responsibilities of each CCG include:
- Planning services based on the needs of the local population.
- Securing services that meet the needs of the local population.
- Monitoring the quality of care provided.
Clinical focus and adding value
- It is essential to fully engage all health professionals. Effective services must have the full participation of the healthcare professionals who deliver them. Setting some early 'easy wins' can help to engage colleagues and patients and therefore build confidence in the process.
- The setting of priorities must be based on local health needs, on the use and performance of each service and on patient outcomes.
- Commissioners have a key role (in partnership with service providers) in designing services to meet local priorities.
- The CCG will be responsible for ensuring that demand for services is kept in line with the capacity to provide each service.
Engaging with patients, carers and communities
- CCGs should build partnerships with patients and the public, not only as the recipients of care but also to involve the whole community in the CCG's vision, priorities and plans.
- The CCG must remain patient-focused and make sure any changes make a real difference to patient outcomes.
- To be effective, each CCG should evaluate the needs of the population and should shape the provision of services based on patient and public need.
- CCGs must protect the needs of the vulnerable, the overlooked and the ignored and promote the health and well-being of the whole community.
- Managing media and communication plays an essential role in shaping the relationship with patients, the public and other bodies.
Delivering quality services and improving productivity
- Each CCG must identify and prepare for future developments in patient need and prepare for changes in the healthcare provider market.
- CCGs should encourage providers to innovate and participate in research and development and maintain systems to support the spread of innovation and implementation of evidence-based practice.
- Continual quality improvement can be enhanced through relationship with providers, contracting arrangements and being a source of expertise.
- CCGs should act as careful stewards of resources in order to promote sustainability of service provision.
- A CCG's own operations should be efficient and ecologically sound and commissioning plans should reduce wasted natural, financial and human resources.
- CCGs should work in partnership with other agencies to provide individuals, practices and teams with access to high-quality education, training and support.
Organisational, governance and financial responsibilities
- A CCG is responsible for the commissioning of services, ensuring contract systems operate well, serving strategic goals, investing wisely and managing risk appropriately.
- Effective leadership and strategic planning and management are essential for each CCG.
- The market of providers should be shaped to ensure the sustainable provision of the right range of accessible, high-quality services for patients.
- Contracts are one way to drive continual improvements in quality for patients and the public.
- Each CCG will be held to account for its activities, including managing its finances to ensure value for money, managing risk, ensuring probity and improving the health outcomes of the local population.
- Robust governance arrangements are crucial and it is vital to establish clear rules on conflicts of interest in line with the NHS Commissioning Board guidance from the start.
Working and commissioning collaboratively
- Each CCG needs to form a variety of strong strategic partnerships with other organisations. The partnerships should integrate with the group's overall vision, have a clear purpose, effective governance and appropriate safeguards.
- CCGs in partnership with local authorities can make an ideal partnership for improving outcomes for their communities.
- Commissioning of some services is best undertaken for a population that is larger than that covered by many CCGs. Your CCG needs to develop relationships and agreements with other commissioning groups in order to commission the services jointly and to share expertise and risk.
- Services are best designed using a multidisciplinary partnership of clinicians and managers from primary, secondary, tertiary, community and any other providers.
Leading individually and collectively
- Each member of a CCG, like any other health professional, must attend to their personal skills, well-being and professional development.
- Effective shared leadership acknowledges the contribution of the whole team to successful outcomes.
- Effective clinical leaders have to look beyond the status quo, motivating others with a vision of a different, improved future. Being able to articulate the vision in a clear way is essential.
- CCGs need clinicians with the skills to turn good ideas and team commitment into successful change as efficiently and sustainably as possible.
Further reading and references
Gerada C; What should clinical commissioning groups do on 1 April 2013? BMJ. 2013 Mar 26346:f1977. doi: 10.1136/bmj.f1977.