Clinical Commissioning Groups, Providers, Local Authorities, and Healthwatch – A Guide to key changes in the NHS.
Dr Hakim walks us through the terminology, the changes in commissioning of care, and local bodies whose role it will be to scrutinise commissioning. At the end is a summary of ways to get involved in shaping local healthcare.
In 2011 and 2012 Clinical Commissioning Groups (CCGs) started to shadow the then existing Primary Care Trusts (PCTs). From April 2013 CCGs have taken over from PCTs and PCTs are no more. CCGs have to work closely with Hospital and Community Providers of care, the Local Authority, and local Healthwatch.
The full extent of these changes was set out in the Governments White Paper published in July 2010, “Equity and Excellence: Liberating the NHS”. The White Paper is available to download at:
What do all these terms mean, who are the people involved, what do they do, and how can we be involved?
This is the term used to describe they ways in which ‘commissioners’ choose and buy our health and care services. It is important to understand that the commissioners do not buy our social care services. The Local Authority looks after social care. We will discuss this later in the article.
Commissioning is a continuous cycle of annually reviewing and agreeing contracts for health services. The contracts that are agreed and monitored specify the services to be delivered, the teams expected to deliver them, and the standards of care expected. The standards expected will be about both ‘Quality and Safety’ of care (excellent patient experience and satisfaction) and about ‘Performance’ (meeting all the targets in the contract such as the number of patients to be seen and cared for, short waiting times to be seen etc).
Commissioning should ensure that local health and care services effectively meet the needs of the local population within the resources available. This work was undertaken by PCTs but is now to be undertaken by CCGs.
Clinical Commissioning Groups
These are groups of GPs that from April 2013 have become responsible for designing and buying local health services In England. The desire to put GPs ‘in the driving seat’ of commissioning health care services was part of the Government’s wider desire to create a ‘clinically-driven’ NHS that is more sensitive to the needs of patients.
All NHS GP practices will belong to a CCG.
CCGs vary in size up and down the country. A good guide to where and who they are can be found on the Guardian Newspapers Interactive Map
Some CCGs are relatively small; they may be made up of 20-30 GP practices and look after around 100,000 patients. A few CCGs are very large, such as ones found in Southwest England, Sussex, and Cumbria with as many as 400-500,000 patients. Also, many CCGs have joined together in groups of 3-5 with an over-arching body often called a ‘Senate’, ‘Polysystem’, or ‘Collaborative’. Senior representatives from each CCG sit on this collaborative with the aim of managing the whole of a local health system together in a coordinated way.
CCGs work with patients and healthcare professionals and in partnership with local communities, local authorities and local providers.
Each CCG has a governing body made up of GPs, a least one registered nurse and a hospital doctor who is a secondary care specialist. Surrounding them is a team of administrative experts supporting finance, contracting, staff employment etc.
Each CCG will also develop clinical working groups with local patients and providers to identify the services needed and changes that can improve existing services.
Providers are those organisations and teams that actually deliver the health care. Commissioners do not deliver the health care. These are our hospitals, community clinics and other community services. Providers can come from existing NHS organisations or from private sector healthcare companies. Providers have to compete for new commissioner contracts through tendering processes like any other in an open market.
So the CCGs buy care by contracting Providers to deliver the care. Typically CGGs will think about provision of care that they want from local Providers in 5 main categories:
- Elective care – things like out-patients clinics, planned surgery, planned investigations/tests, Maternity services, planned treatments (medication and therapies such as physio.).
- Urgent and Emergency care – out-of-hours GP urgent clinics and walk-in centres, A&E services, and emergency admissions to hospital.
- Rehabilitation services – this may be while recovering from surgery e.g., a joint replacement, or while improving general well-being and mobility e.g., a frail or older person recovering from an illness, or after a stoke for example.
- Most Community Health Services – things like managing long term conditions, community specialist nurses, GP specialty clinics, therapies, wound services, blood tests, childrens services, womens services, well person checks etc.
- Mental Health and Learning Disability Services – including community mental health support, alcohol and drugs support, and mental health hospital admissions.
National Commissioning Board
CCGs are overseen by the NHS Commissioning Board.This Board makes sure that CCGs have the ability to undertake the task and meet all their responsibilities, which include their financial responsibilities.
About 75-80% of all the money in the Governments budget for healthcare in England will be devolved to the CCGs. The NHS Commissioning Board will retain the rest for things like:
- Pharmacy services
- Dentistry services, and
- SubSpecialist services (these are specialised services that are required by small numbers of people with rare conditions – this would include for example the provision of the genetic service for people with Classical and Vascular Ehlers Danlos Syndrome or Marfan Syndrome). The commissioning of these conditions is to be managed by 10 bodies in England called National Specialised Commissioning Groups (NSCG).
Health and Wellbeing Boards & Healthwatch
At a local level, new Health and Wellbeing Boards will be set up in Local Authorities to ensure that CCGs are meeting the needs of local people. The membership of these boards will likely include representatives from:
- Directors of public health
- Children’s services
- Adult Social Services
- Elected councillors
- Healthwatch (representing the views of patients, carers and local communities)
Shadow health and wellbeing boards were put in place in each local authority by April 2012. Subject to Parliamentary approval they should be fully established in 2013.
Healthwatch is a new patient champion that was established in April 2012. Its role is to ensure that patients are involved in decisions about their care and that their views are considered. At present there should already be Local Involvement Networks (LINks) in each Local Authority area. These were set up to represent views of local people on health and social care services. The LINKs will become the local Healthwatch.
Among its varied roles the local authority is responsible for providing social care services, which it may contract from independent providers. Social service provision aims to support individuals with difficulties coping with daily life and basic needs. The services provided can be things like:
- Long term conditions health care
- Help in the home
- Financial support
- Advisory / Advocacy service
- Support for carers
Find your Local Authority here.
How can we be involved in shaping local health care?
At a National level it is important for the HMSA alongside its allied partner charities and the Arthritis Musculoskeletal Alliance to work closely with the Department of Health in defining standards of care for patients with musculoskeletal conditions.
Much of this work has been ongoing for a couple of years now. National specialty organisations such as the British Orthopaedic Society and The British Society for Rheumatology have and continue to make significant representations to Government. Hypermobility Syndromes have been amongst the conditions discussed at this level.
At a local level we can be involved in shaping CCG decisions on the commissioning of services. This might include sitting on clinical working groups defining services such as community physiotherapy and musculoskeletal services.
If patients or carers wish to sit on any of these committees it is important to bring a very broad view of care of long term conditions to the table. A focus just on Hypermobility will not be helpful. Many of the issues HMSA members have with things like access to therapy long term, limited expertise in the areas of care needed, need for joined up working between specialty teams, and access to subspecialty expertise outside the local health economy, will very likely be the same as those for other patient groups.
As well as the CCG working groups, consider a role supporting LINKs / Healthwatch and help with things like raising concern over changes to service, or informing the CCG Governing Body of gaps in local services.
Dr Alan J Hakim MA FRCP
Consultant Physician and Rheumatologist
Hon. Senior Lecturer
Barts Health NHS Trust and Queen Mary University London
Also: Member of Board, CWHH CCGs Collaborative, Inner Northwest London
Chief Medical Advisor & Trustee HMSA
Regional Chair, Council Member, British Society for Rheumatology
Updated June 2013, adapted from HMSA Newsletter Sept 2012. Planned Date of Review June 2015