Clinical commissioning groups are NHS organisations set up by the Health and
Social Care Act 2012 to organise the delivery of NHS services in England.
To a certain extent they replace primary care trusts, though some of the staff
and responsibilities moved to Local Authority Public Health teams when PCTs
ceased to exist in April 2013. Services directly provided by PCTs were
reorganised through the Transforming Community Services programme.
Structure and membership CCGs are clinically led groups that
include all of the GP groups in their geographical area. The aim of this is to
give GPs and other clinicians the power to influence commissioning decisions for
their patients. CCGs are overseen by NHS England. These
structures manage primary care commissioning, including holding the NHS
Contracts for GP practices NHS. Each CCG has a constitution and is run
by its governing body. Each has to have an accountable officer responsible for
the CCG’s duties, functions, finance and governance. Most CCGs initially
appointed former PCT managers to these posts. Only a quarter of accountable
officers were GPs in October 2014, but 80% of CCG Chairs were GPs. Only half of
GP practices said they felt involved in CCG decision making processes. The
Health and Social Care Act 2012 provides that the areas specified in the
constitutions of clinical commissioning groups together cover the whole of
England, and do not coincide or overlap. Each CCG is responsible for persons who
are provided with primary medical services by a member of the group, and
persons who usually reside in the group’s area and are not provided with
primary medical services by a member of any clinical commissioning group.
E-reward, an online pay research service, analysed the pay of more than
2,500 managers at the 211 CCGs in England in 2015. They reported that 56%
of 225 top executives – chief officers and chief finance officers – were paying
themselves more than the salary range recommended by NHS England of £95,000 to
£125,000 a year. Unite the Union surveyed the 3,392 CCG
board members in 2015 and reported that 513 were directors of private healthcare
companies: 140 owned such businesses and 105 carried out external work for them.
More than 400 CCG board members were shareholders in such companies.
Operation CCGs operate by commissioning healthcare
services including: Elective hospital care
Rehabilitation care Urgent and emergency care
Most community health services Mental health and learning disability
services Clinical commissioning groups are
supposed to work with patients and healthcare professionals and in
partnership with local communities and local authorities. On their governing
body, each Group has, in addition to GPs, at least one registered nurse and a
doctor who is a secondary care specialist. Clinical commissioning
groups are responsible for arranging emergency and urgent care services
within their boundaries, and for commissioning services for any
unregistered patients who live in their area. All GP practices must belong to a
clinical commissioning group. As originally established CCGs did not have
any responsibility for Primary Care which was commissioned and managed by
NHS England. In November 2014 CCGs were invited to become co-commissioners of
primary care in their area. They would be responsible for the performance
management and budgets of their member GP practices, including managing
complaints about practices and GPs. 63 will take on fully delegated
responsibility in April 2015 and 87 which will begin "joint commissioning",
which involves less responsibility. Tower Hamlets Clinical Commissioning
Group, which is chaired by Sam Everington, was awarded Clinical
Commissioning Group of the year by the Health Service Journal in November 2014.
The judges praised the group’s “strong leadership, especially around clinical
leadership, while retaining patient focus.”
A study conducted by the Open University and University College London in May
2015 found that clinical leaders “seemed to be more willing to challenge or
ignore diktats and messages from above, and to encourage their managerial
colleagues to do the same”. Prof Martin Marshall said clinical leaders were more
“focused on outcomes and less interested in processes. They don’t really mind how
they do things as long as they feel they’re having an impact” Having the
option of returning to full time clinical practice meant that clinicians
felt a “degree of freedom in what they say and do”.
Guidance issued in August 2015 provides that if CCGs which have been in special
measures for more than a year NHS England can “trigger changes in the
management, governance or structure of the CCG’s responsibilities, with the
potential for other CCGs or relevant bodies to take over aspects of the local
commissioner’s responsibilities”. None have yet been placed in special
measures. Commissioning
The Centre for Health and the Public Interest estimated in 2015 that there
were about 53,000 contracts between the NHS in England and the private sector,
including contracts for primary care services of which the 211 CCGs currently
hold 15,000 with an annual value of about £9.3bn in 2013-14. They sent
Freedom of Information requests to all 211 CCGs, seeking information about how
they monitor contracts with private providers and concluded that CCGs failed
to manage contracts with private providers effectively.
According to Christian Mazzi, head of health at Bain & Company, in September
2015 70% of CCGs had failed to monitor their private sector contracts or
enforce quality standards. 12% had not carried out any visits to private
providers, but 60% could not say if they had done so.
CCGs are responsible for dealing with Individual Funding Requests in their
area. A survey of CCGs by the Health Service
Journal in April 2015 found that more than a third were planning to save money
by restricting access to services, particularly on “procedures of limited
effectiveness”, podiatry, IVF, and limiting access to procedures based on
aspects of a patient’s health, for example whether they smoke or are obese,
which can affect outcomes. A similar survey by the GP magazine Pulse, in July
2015, found that many CCGs were planning to restrict access to routine care in
various ways. 25 Commissioning Support Units were
established in April 2013 by NHS England to provide a variety of support
functions, largely staffed by former employees of the Primary Care Trusts.
All CCGs were told that they must procure support services by a tender
process by April 2015. The first tender, by South Lincolnshire and South West
Lincolnshire CCGs was won by OptumHealth with a value of £3 million a year for 3
years. = Incentives and referrals=
It was reported in September 2015 that at least 9 CCGs had set up “ethically
questionable” incentive schemes to persuade GPs to reduce referrals for new
outpatient attendances, follow-ups, A&E attendances and emergency admissions
with payments per practice of up to £11,000. Dr Chaand Nagpaul, of the
British Medical Association, condemned them as “a financial contaminant” to
patient-doctor trust. The General Medical Council guidance, Financial and
commercial arrangements and conflicts of interest provides that a doctor should "
not allow any interests you have to affect the way you prescribe for, treat,
refer or commission services for patients" but the council accepted that
"Finance and other incentives can be an effective way of driving improvements in
healthcare." = Service restrictions=
In September a survey by the Health Service Journal showed that 34 of 188
CCGs who responded to the survey had restricted access to some services.
Restrictions were usually introduced by a number of CCGs acting together across
an area. Nottinghamshire CCGs had restricted access to surgery for sleep
apnoea and hysterectomy for heavy menstrual bleeding, fat grafts, hair
depilation, earlobe repair, and chin, cheek or collagen implants.
See also Health care rationing. History
The announcement that GPs will take over this commissioning role was made in the
2010 White Paper, "Equity and Excellence: Liberating the NHS". This
was part of the Government's advertised desire to create a clinically driven
commissioning system that was more sensitive to the needs of patients. The
2010 White Paper became law under the Health and Social Care Act 2012 in March
2012. At the end of March 2013 there were 211
CCGs. Authorisation
All CCGs had to go through an authorisation process. There were four
waves of authorisation between July and December 2012.
Regulation In 2014 NHS England investigated Wirral
Clinical Commissioning Group after Birkenhead MP Frank Field raised
concerns about it. They found that the chair and chief clinical officer “did
not demonstrate the necessary close working agreement” about what needed to
change within the CCG. There were also questions about the relationship senior
leaders had with Arrowe Park Hospital. After the report was published Field
repeated his calls for the senior officers to stand aside while a new
constitution is made for the governance of the group.
In October 2014 it was reported that NHS England were considering a special
measures regime for CCGs in difficulties, of which there were said
to be about a dozen. Under the current assurance framework, CCGs are rated as
“assured”, “assured with support” or “not assured”. Only Barnet CCG has been
rated “not assured”. Public involvement
Bristol CCG were subject to a legal challenge from a local pressure group,
Protect Our NHS, who claimed that their processes for involving patients and the
public in their decisions were inadequate. A judicial review was
withdrawn in June 2014 after the CCG agreed to amend its patient and public
involvement strategy and other documents.
See also Category:Healthcare in England by county
for local commissioning issues References
External links List of Clinical Commissioning Groups]
Health and Social Care Act 2012 - full legislation
NHS England website