The new NHS Commissioning Landscape

8 October 2012

Nigel LittlewoodHead of Commissioning Development, NHS London

1. NHS Commissioning Board

2. Clinical Commissioning Groups

3. Commissioning Support Units

4. Similarities, differences, challenges and opportunities

5. Discussion

NHS Commissioning Board

NHS Commissioning

Board

Providers

FundingAccountabilityOther

Parliament

Patients and Public

Local HealthWatch

contract

Health & Wellbeing Boards (HWBs)

Public Health

England

Clinical Commissioning Groups (CCGs)

contract

cont

ract

Monitor

contract

Local Authorities (incl. Public Health)

Commissioning Support Services

NHS Trust Development

Authority

NHS Trusts

Joint licensing between Monitor and CQC

CQC

Nat

iona

lR

egio

nal

‘Foo

tprin

t’ /

Loca

l

Health Education England

DH (SoS)

NHS CB (London)

Clinical Networks

NHS TDA(London)

FTs

London LETBs

Work together to

ensure commissioner

support for aspirant FTs

Clinical Senates

Following Royal Assent of the Health and Social Care Bill, the NHS landscape will look very different from April 2013

Public Health

(London)

HealthWatch England

Independent SectorAccountability for results

Primary Care

contractors

contract

Commissioning Assembly

London Clinical Commissioning Council

NHS Property Services

NHS Prop

Services (London

)

Information Centre

NHS Commissioning Board was established as an ENDPB on 1 October 2012

Chief Executive

David Nicholson

Chief Operating Officer

Ian Dalton

Chief of Staff 

Jo-Anne Wass

Director Commissioning Development

Barbara Hakin

Patient Engagement,

Insight & Informatics

Tim Kelsey

Director Policy, Corporate

Development and Partnership

Bill McCarthy

Director Improvement

and Transformation

Jim Easton

Finance

Paul Baumann

Medical Director

Bruce Keogh

Nursing Director

Jane Cummings

Chair

Malcolm Grant

Non-executive directors

Ed Smith

Ciaran Devane

Margaret Casely-Hayford

Dame Moira Gibb

Mr Naguib Kheraj

Lord Victor Adebowale

The NHS Commissioning Board has a number of main functions

• Oversight and leadership of the new commissioning system including assuring and supporting CCGs to develop

• Oversee commissioning budgets including financial control and VFM• Direct commissioning of around £20bn/£80bn of services, including specialised

services, primary care, military health, offender health, and some services on behalf of Public Health England such as screening and immunisations

• Agree and deliver improved outcomes and account to Parliament• Support quality improvement ensuring consistency of standards• Develop commissioning guidance, standard contracts, pricing mechanisms and

information standards• Increasing choice for patients and championing their interests• Ensuring plans for emergency resilience

There will be four regional offices of the NHS Commissioning Board, each led by a regional director and reporting to the Chief Operating Officer. Within each region there will be local area teams roughly reflecting current PCT clusters

Co-ordination and oversight of local area teams

Management of delivery of specialised commissioning

Support and co-ordination of clinical senates and networks

Performance oversight, including intervention and failure regime

Involvement in large scale reconfigurations Co-ordination and oversight of emergency

preparedness Stakeholder engagement, particularly with

sub national presence of bodies such as CQC and Monitor

Information functions

Managing the Board’s day-to-day relations with CCGs, including providing development support, and monitoring performance and outcomes

Direct commissioning, covering offender health; military health, specialised commissioning; and primary care, including management of family health service functions

Professional and clinical leadership Partner and stakeholder engagement,

including representation on Health and Wellbeing Boards

NHS CB regional offices – North, Midlands and East, South and London

Local Area Teams of NHS CB reporting to each region. London has integrated region and LAT functions.

Regional Directors have been appointed and are appointing to their structures London - Dr Anne Rainsberry Midlands & the East - Dr Paul Watson South of England - Andrea Young North of England - Richard Barker

The structure of the London regional team has been recently published

Medical Director

Director of Nursing

Finance Director

Director of Operations and

DeliverySimon Weldon

Director of Commissioning

Business Office

RegionalDirector

Anne Rainsberry

HR DirectorDirector for Patients and Information

Transformation Director

Clinical Commissioning Groups

CCGs are meant to be genuinely new organisations not simply a recreation of previous commissioning bodies

10

Secretary of State through

Department Health

PCT Board

Responsible for delivering Functions,

Duties and Powers

Defines Functions, Duties

and Powers

Chief Executive& Executive Team

Acc

ount

able

for

del

iver

ing

Fun

ctio

ns,

Dut

ies

and

P

ower

s Chair and Non-execs

App

oint

sA

ppoi

nts

GP Practice

GP Practice

GP Practice

GP Practice

Governing B

ody

Chair + Deputy

AO

CFO

Any Others

2 ** Lay

2 x Clinician*

NH

S C

omm

issioning Board

Oversee and ensure

enacted

Appoint

Accountable to

Accountable

on behalf

of CCG

NHS CCG

Current lines of decision-making and accountability

Future lines of decision-making and accountability

*The two clinicians must be a secondary care doctor and a nurse (nurse cannot be a primary care nurse employed/with interests in a practice)** There must be a minimum of two lay members. One lay member will cover Patient and Public Involvement, the other will cover financial management and audit

Camden

Hillingdon

Harrow

Brent

Ealing

Hounslow

Central London (Westminster)

Barnet

Enfield

Haringey

Islington

Richmond

Merton

Croydon

Wandsworth

Kingston

Bromley

Bexley

Greenwich

South-wark

Lambeth

NewhamTower

Hamlets

City & Hackney

Havering

Redbridge

Waltham Forest

Sutton

Ealing CCG has the largest population (c.390k) and number of GP practices (82). Central London (Westminster) CCG has the smallest population (c.130k)

All are coterminous with their local authorities except for: City & Hackney CCG covers the boroughs of Hackney and the City of London. West London CCG covers the whole of Kensington & Chelsea and 12 practices in Westminster

Wave 1 – 3 CCGs

Wave 2 – 11 CCGs

Wave 3 – 11 CCGs

Wave 4 – 7 CCGs

Barking &Dagenham

Hammersmith & Fulham

West London (K&C, QPP)

Lewisham

Camden

There are 32 proposed CCGs in London

Kingston and Richmond share a CFO

Kingston shares their AO with the Local Authority

Inner NWL CCGs are sharing one AO and CFO

Outer NWL CCGs are sharing one AO and CFO

All CCGs in NCL are having their own AOs and CFOs

2 NEL CCGs with their own AOs, but sharing 1 CFOs

3 NEL CCGs sharing one AO and CFO

All CCGs across the South, except Richmond and Kingston currently want their own AO and CFO

The authorisation process is underway now

• 212 CCGs nationally are being assessed in 4 waves against 6 domains and 119 criteria

• The 6 domains are:– A strong clinical and professional focus – Meaningful engagement with patients, carers and their communities– Clear and credible plans which continue to deliver the QIPP challenge – Proper constitutional and governance arrangements– Collaborative arrangements for commissioning with partners– Great leaders who individually and collectively can make a real difference.

• There are 3 outcomes of the process:– Fully authorised with no conditions– Partially authorised with conditions– Established but not authorised

• The NHS CB will be working with CCGs to support them to meet any conditions ahead of April 2013

Evidence will be assessed against both the legal criteria of the Act, and the 6 domains

Conditions Panel

Conditions Panel

Conditions Panel

Conditions PanelAuthorisation Final Decision

Board / Delegated Committee of NHSCB

Commissioning Support Units

CCGs have £25 per head running costs to pay for their internal costs as well as a range of commissioning support services

15

Category Function / Service

Health Needs Assessment Health needs assessment and forecasting (e.g. JSNA/HNA)

Provider Management Clinical governance and quality support (e.g. SUIs)Contract monitoring, quality and performance managementSafeguardingIndividual Funding Requests and complex case management

Procurement and Market Management

Provider market assessment and developmentContract definition and negotiationProcurement servicesSupport for joint commissioningMedicines management and prescribing servicesContinuing care and funded nursing care

Business Intelligence Data capture, management and integration as per “the national at scale definition”Performance and activity reporting.Advanced and specialist analytic services

Support for commissioning strategy and service redesign

Commissioning intentions planning and support (e.g. CSPs)Health care efficiencies planning (e.g. QIPP)Support for clinical service change / pathway redesignPlanning, management and implementation of service redesign

Communications and PPE Patient InvolvementStrategic CommunicationsPatient Experience

Business and Corporate Support (including back office functions)

Financial planning, budgeting and analysis.Financial reporting and accountingPayroll and staff administration.Data infrastructure servicesHR supportLegal adviceGovernance (corporate and information)

Three CSUs are taking shape in London, developing cost effective services that meet the needs of their CCG customers

16

North West London

South London

North Central and East London

Similarities, Differences, Challenges and Opportunities

There are a number of similarities with the current system

• A continuation of the basic arrangements :- Purchaser provider split more pure- Local, regional and national levels - Local strategic partnerships

• National planning requirements• A continuing focus on financial challenges (QIPP) and meeting growing health needs• PBR Tariff system continues, although this needs promote integrated whole system

care pathways • Development of the market and AQP continues as a commissioning tool• Further focus on integrated care, population health, prevention, early intervention,

long term conditions management• The need to manage demand and developing care closer to home• Ongoing patient choice agenda and strengthening of patient voice, including

Healthwatch

There are a number of differences to the current arrangements in terms of commissioning

• 32 CCGs in London will be statutory, practice based member organisations • The Mandate and Commissioning Outcomes Framework will drive improvement• The Quality Premium will provide an incentive • Commissioning Support Services set up, with CCGs having choice• Local authorities will commission most public health services• Health and Well Being boards will be driving local strategies• There will be no statutory organisation at regional level • NHS CB also will be a significant commissioner of services and may be the majority

commissioner for some London hospitals • Contracts for specialised services for London providers will be managed by the NHS

CB London team on behalf of the country• Clinical senates and clinical networks will be formal parts of the system• A number of commissioners will commission services along patient pathways• NTDA will manage non FT trust performance, working with commissioners

There are a number of challenges with the new commissioning arrangements

• Transition of 5 500 London staff from 9 organisations to 75• Not losing the opportunity to deliver transformation• Giving CCGs space whilst needing grip in the system• For CCGs, keeping their membership on board and engaged• NHS CB commissioning for established but not authorised CCGs• CSUs supporting CCGs rather than leading• Ensuring that commissioners collaborate across the pathway• Driving integration of services and integrating commissioning as appropriate• Health and Well Being boards ensuring implementation as well as local strategic

improvement• Tackling large scale change when pan London health leadership in the system is not

clear

The new commissioning arrangements should deliver a number of benefits

• Greater clinical input into decision making • More buy in from GP members of CCGs and a focus on population health as well as

individuals • Public health largely commissioned by local government• Health and Well Being Boards providing a local population focus and joint decision

making• Much more freedom locally for CCGs and Health and Well Being Boards to set

priorities and to innovate• Commissioning support services operating at scale, customer and business focussed• The need for close collaboration between commissioners• Greater consistency of specifications and standards • Greater efficiency with the NHS CB’s single operating model

Discussion