The Health and Social Care Act 2012 gave the power and responsibility for commissioning health services and budgets to groups of GP practices called Clinical Commissioning Groups (CCGs). CCGs will commission the great majority of NHS services for their patients but will not be directly responsible for commissioning services that GPs themselves provide. The responsibility for commissioning primary care services (medical, dental, eye health, and pharmacy) was given to a new statutory organisation called NHS England (NHSE), known as the NHS Commissioning Board in statute. This was to ensure a more standardised model and consistency in the management of the four groups.
In May 2014, following Simon Stevens appointment as the Chief Executive of NHS England, CCGs were delegated the responsibilities to commission primary care services. This was to enable better integrated care outside hospitals, ensure that primary, community and mental health are properly resourced, and CCGs having more influence over how funding is invested for local population, which would ensure sustainability of their local NHS. Co-commissioning would also enable the development of new models of care such as multispecialty community providers (MCPs) and primary and acute care systems (PACSs), as set out in the NHS Five Year Forward View.
This report presents the findings from a study following the development of Clinical Commissioning Groups (CCGs) in England. This is the third phase of the project, which aims to understand the ways in which CCGs are responding to their new primary care co-commissioning responsibilities from April 2015, providing feedback to NHSE supporting CCGs going through the approval process.
The study provides detailed evidence about the experiences of CCGs as they took on delegated responsibility for primary care commissioning. The study took place between May 2015 to June 2017. The strength of this study lies in the bringing together of evidence from senior policy makers as to the overall objectives for the policy with both telephone survey and case study evidence as to how it is playing out in practice. The specific research questions addressed in this report are:
- What is the scope of co-commissioning activity and the process of change?
- What approaches have been taken by CCGs to:
- Develop governance structure to oversee primary care co-commissioning?
- Commissioning and contracting?
- Manage and develop the relationships between CCGs and their membership and between CCGs and external stakeholders?
- Manage conflicts of interest?
- What are the impacts and outcomes CCGs would expect from taking on delegated responsibility and claims of early successes?
- What factors have affected CCGs’ progress and development?
Download report [pdf]>>
Download executive summary [pdf]>>
Since the establishment of PRUComm in 2011 our research has focused on examining how the changes to the English NHS and public health system have developed. We continue to examine the development of CCGs and the new commissioning structures. We have also been exploring the mechanisms by which commissioning is undertaken, such as contracting and the use of competition and cooperation within the new system.
While most media attention has focused on changes to the commissioning and delivery of healthcare, the shift of public health to local authorities was a major part of the reforms introduced in April 2013. We have examined the progress and developments in the public health system with a particular emphasis on how governance and organisational structures develop and whether being embedded within local councils changes the way that public health services are provided. We have also been focusing on primary and community health care with recent projects examining general practice – including methods of funding primary care; research on recruitment and retention; QOF, scaling up primary care and running and analysing two rounds of the GP WorkLife survey (eight and nine).
Our research on CCGs has most recently focused on primary care co-commissioning and new forms of contracting, such as outcomes-based and alliancing. Given the increasing policy emphasis on this area of healthcare we anticipate that we will be increasingly involved in further research on primary and community healthcare. All these topics will be explored in today’s seminar with presentations by researchers from PRUComm.
Programme and speakers biographies [pdf]>>
9.30 Registration and refreshments
10.00 – Welcome and introduction: Professor Stephen Peckham (Director PRUComm).
10.00 – 10.25 Jonathan Walden: (Commissioning Policy Lead): Policy update – Department of Health and Social Care priorities. Slides [pdf]>>
10.25– 11.00 Dr Lindsay Forbes: Incentivising GPs: Review of the Quality and Outcomes Framework in England. Slides [pdf]>>
11.00 – 11.20 Coffee
11.20 – 12.00 Dr Jon Gibson and Prof Kath Checkland: Satisfaction, sources of stress and intentions to quit amongst GPs in England: the results of the 9th GP Worklife survey
12.00 – 12.40 Dr Marie Sanderson: Examining the implementation of new models of contracting in the NHS: what are the lessons for the formation of Accountable Care Systems?
12.40 – 13.20 Lunch
13.20 – 14.00 Dr Valerie Moran: How are CCGs managing conflicts of interest when they commission primary care? Lessons for Accountable Care. Slides [pdf]>>
14.00 – 15.50 Panel Discussion – STPs, and ACS’s the re-emergence of planning?
15.50 – 16.00 Professor Stephen Peckham: Current PRUComm research programme
Posted in CCG, Commissioning, Competition & cooperation, Contracting, Deputy Director of PRUComm, Director of PRUComm, Public Health, Seminar, Stephen Peckham
Tagged alliance contracting, CCG, CCGs, co-commissioning, commissioning, Competition, Contracting, Cooperation, England, FYFV, GP, HSCA2012, new care model, new models of care, NHS, planning, policy, policy-making, primary care, PRUComm, Public Health, QOF, Quality, STP
Objectives From April 2015, NHS England (NHSE) started to devolve responsibility for commissioning primary care services to clinical commissioning groups (CCGs). The aim of this paper is to explore how CCGs are managing potential conflicts of interest associated with groups of GPs commissioning themselves or their practices to provide services.
Design We carried out two telephone surveys using a sample of CCGs. We also used a qualitative case study approach and collected data using interviews and meeting observations in four sites (CCGs).
Setting/participants We conducted 57 telephone interviews and 42 face-to-face interviews with general practitioners (GPs) and CCG staff involved in primary care co-commissioning and observed 74 meetings of CCG committees responsible for primary care co-commissioning.
Results Conflicts of interest were seen as an inevitable consequence of CCGs commissioning primary care. Particular problems arose with obtaining unbiased clinical input for new incentive schemes and providing support to GP provider federations. Participants in meetings concerning primary care co-commissioning declared conflicts of interest at the outset of meetings. Different approaches were pursued regarding GPs involvement in subsequent discussions and decisions with inconsistency in the exclusion of GPs from meetings. CCG senior management felt confident that the new governance structures and policies dealt adequately with conflicts of interest, but we found these arrangements face limitations. While the revised NHSE statutory guidance on managing conflicts of interest (2016) was seen as an improvement on the original (2014), there still remained some confusion over various terms and concepts contained therein.
Conclusions Devolving responsibility for primary care co-commissioning to CCGs created a structural conflict of interest. The NHSE statutory guidance should be refined and clarified so that CCGs can properly manage conflicts of interest. Non-clinician members of committees involved in commissioning primary care require training in order to make decisions requiring clinical input in the absence of GPs.
Read the BMJ Open article >>
Read the blog>>
Posted in CCG, Commissioning, Deputy Director of PRUComm, Publications
Tagged CCG, CCGs, co-commissioning, commissioning, general practice, GP, HSCA2012, NHS, primary care
This is our fifth annual review of research and provides a brief overview of our research activities. Following confirmation last year of our extension until the end of 2018 we have now agreed a programme of work with the Department. This sees a stronger shift towards exploring the impact of system changes on commissioning. The introduction of Sustainability and Transformation Plans and new metapractice organisations creates a rapidly shifting landscape for the commissioning and delivery of healthcare in England.
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Posted in Director of PRUComm, Publications, Stephen Peckham
Tagged alliance contracting, CCG, co-commissioning, commissioning, Competition, Contracting, Cooperation, NHS, primary care, Public Health, QOF, STP
The Quality and Outcomes Framework (QOF), an incentive scheme in general practice, was introduced across the UK in 2004 to link payment to delivery of primary medical care. Drivers for its introduction included the recognition that there were variations between general practices in the quality of care and the need to increase investment to improve morale and recruitment in primary care. QOF, in the early years, led to a reduction in inequalities in delivery of those aspects of care that it incentivised. Currently, there is little variation in QOF achievement between practices – most derive maximum, or near maximum income from it.
The QOF had other effects, encouraging nurse-led multidisciplinary management of chronic disease to deliver incentivised services, and better practice computerisation, so that delivery could be recorded. However, the extent to which high QOF achievement means a higher quality service in general practice is not clear. Quality in primary care is difficult to define, but it certainly encompasses more than is measured by QOF. It is now explicit NHS policy to improve other aspects of primary care – in particular, to deliver better integrated, holistic and patient-centred care and more effective primary prevention in primary care. Whether QOF can deliver these policies has been questioned, as have its role in reducing inequalities and its ability to deliver better population health.
NHS England commissioned the Centre for Health Services Studies at the University of Kent, on behalf of the Policy Research Unit in Commissioning and the Healthcare System (PRUComm), to review the evidence of effectiveness of QOF in the context of a changing policy landscape. We examined the most recent evidence that QOF influences behaviour in general practice and health outcomes, taking a broad view of primary care quality. We also considered the evidence that QOF helps sustain changes in primary care and effects of withdrawing QOF indicators using recent patterns of QOF achievement and the published literature.
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The Health and Social Care Act 2012 gave the responsibility for commissioning primary care services to NHS England (NHSE). Part of the rationale for this was to move towards a more standardised model of primary care commissioning. However, it has become clear since 2010 that local flexibility and understanding is also required in order to properly match primary care provision to the needs of an aging population. Primary care co-commissioning was first mooted in the Call to Action in 2014, where “joint commissioning” was identified as one of national level supports to improve general practice. In May 2014, it was officially announced that CCGs would get ‘new powers’ under a new commissioning initiative. There are 3 levels of responsibility; (1) ‘greater involvement’ (where CCGs would have ‘influence’ but not take the lead in shaping primary care locally), (2) joint commissioning (where CCGs would set up a joint committee with NHSE AT), and (3) delegated authority (where CCGs would take over budgets from NHSE Area Teams and take the lead in primary care commissioning). Initially there was no clear expectation that CCGs would move from Level 1 and 2 to taking on full responsibility (Level 3) over time. However, one year on, CCGs operating at Level 1 and 2 were encouraged to consider applying for full delegation. This report aims to explore the uptake of primary care co-commissioning nationally, develop an understanding of the rationale underlying the policy and the expected outcomes, and understand the scope of co-commissioning activity and the process of change.
Download interim report [pdf]>>
Download summary [pdf]>>