As the PCTs form clusters from which the Clinical Commissioning Groups will hatch, a new generation of NHS commissioners is being born. Thoreya Swage examines how medtech can help these new customers to redesign services.
Irrespective of the progress of the Health and Social Care Bill currently going through the House of Lords, the momentum of reform of the NHS in England continues to gather pace.
Following a four-month hiatus while the wise and the good of the NHS Future Forum pondered and produced recommendations for the adjustment of the Bill, the Department of Health published further guidance on the developing role of the PCT Clusters. Although the 151 Primary Care Trusts have been squeezed into 51 PCT clusters in preparation for their demise in April 2013, it appears that they have a vital part to play in the development of the emerging Clinical Commissioning Groups (CCGs).
The guidance or ‘shared operating model’ for PCT clusters has been produced by the mandarins at the DH to ensure that the commissioning landscape is as consistent and smooth as possible in time for the takeover by the CCGs. This is to ensure that the nascent NHS Commissioning Board inherits a robust enough system to take charge of further developments and improvements in healthcare in early 2013.
The shared operating model identifies six main functions or ways of working, where consistency of approach is considered to be important. They are listed as commissioning development, financial and operational issues, ensuring quality, emergency planning, development of providers as Foundation Trusts and communications.
CCG commissioning development
The most important function of the PCT clusters is the preparation of CCGs for authorisation as soon as possible following the successful passage of the Health Bill through Parliament. The process of authorisation to become fully-fledged commissioners is due to begin in the second half of 2012. Although this is a year away, CCGs can commence their preparations now using a self-diagnostic tool: an interactive computer-based assessment that helps them to determine their capabilities and identify their development needs. The areas covered include:
• A clear clinical focus for the CCG commissioning plans to include tackling health inequalities and improving primary care.
• Demonstration of meaningful involvement of patients and the wider community.
• A plan for development that is clear and credible and that, in particular, delivers the QIPP (quality, innovation, productivity and prevention) agenda.
• Capacity and capability of the CCG, i.e. robust constitutional and governance arrangements that enable the CCG to commission care effectively and ensure financial control.
• Collaborative arrangements for working with other CCGs, local authorities and the NHS Commissioning Board.
• Capacity and capability of the CCG leadership, which ensures effective working.
The tool helps the CCGs to identify priority development areas, which form the basis of the developmental plan paving the way to full authorisation.
To support all this work, CCGs will receive £2 per head from the PCT clusters, as well as extra management resources to help the groups hone their commissioning skills and capabilities.
CCGs experiencing difficulty in defining their boundaries will have guidance from PCT clusters on how to resolve this. PCT clusters also have the unenviable task of engaging the reluctant practices that so far have not participated in their local CCG discussions, with the aim of making them part of a viable CCG by October this year.
Separation of functions
Through the last quarter of this year, a detailed exercise is being carried out by the PCT clusters to identify and segregate the service areas that CCGs and NHS Commissioning Board will be responsible for.
Although the CCGs will be commissioning acute, mental health, community and ambulance care, other services that PCTs currently commission will need to be transferred to the umbrella of the NHS Commissioning Board:
• GP and other primary care contractor groups (primary care dental, pharmacy and optical services)
• secondary dental care
• prison, specialised and military health services.
Even though the contracts for GP services are held by another body, the CCGs are expected to have an input into primary care development and improvement.
A vital component of the commissioning process is ensuring the quality of healthcare. Practices may have been involved to a greater or lesser degree in various quality assurance processes in the past; however, CCGs are required to take these responsibilities seriously on board.
There is a whole raft of procedures and measures including delivery of better health outcomes for patients, meeting the Care Quality Commission (CQC) requirements for safety and quality of services, standard contracts, the NHS Operating Framework, professional guidance and other relevant requirements that CCGs need to get to grips with.
This could potentially be a vulnerable time for the development of the CCGs if attention wanders and serious patient safety incidents are not acted on promptly. Clinical governance processes must therefore be extra-secure.
Budgets and responsibilities
Over the next year or so, there will be a period of dual functioning and handover as the CCGs mature and the PCT clusters delegate more and more responsibilities until April 2013. The handing over of the baton has started now, with PCT clusters having identified a ‘clear percentage of budgets’ to CCG pioneers or pathfinders in August and set plans for future delegation of budgets in October.
Sandwiched in between these two was the agreement in September on which mental health and community services will be subject to ‘Any Qualified Provider’ (AQP). This policy is set to be implemented from April 2012, when GPs can refer to providers of certain services eligible for AQP from a list of approved organisations, including private sector companies, drawn up by the DH.
A review of the commissioning support required by CCGs was undertaken in July, with clear arrangements to be agreed by the end of this year.
In March 2012, CCGs will be required to enable the development of the local health and wellbeing boards (the mechanism for joint health and social care planning and local commissioning) supported by their PCT clusters.
Meanwhile, individual PCTs will continue to carry out their statutory functions through the PCT clusters until their abolition in April 2013. The statutory functions include contract monitoring, ensuring that providers meet their QIPP obligations, and other statutory requirements such as safeguarding children and vulnerable adults.
The big challenge for CCGs begins when they are required to lead the next planning round for 2012/13. This will start towards the end of this year, and is a function previously undertaken by the PCTs. It involves doing a needs analysis, identifying local inequalities, understanding demand and resources for local services, negotiating and setting priorities with partners, and developing a local strategic vision. Handover of commissioning functions will continue, with CCGs being an active participant in the subsequent contract negotiations and agreements.
How medtech fits in
It is apparent that despite the pause for reflection on the proposed changes in the English health service earlier this year, the momentum of dissolving and restructuring healthcare organisations continues. The picture remains a little confusing, however, as CCGs are in varying stages of development and maturity and it is not clear that all are now truly viable although the October deadline has passed.
What is clear is that that the work of commissioning and delivering healthcare has to go on, and now is a good time to find out who the key movers are within the CCGs. At this point the developmental needs of CCGs are uppermost, and it is here that medtech companies can provide some input. Skills and knowledge in leadership development and highlighting evidence-based medical technologies that really make a difference are two key areas of potential input.
CCGs will be keen to redesign services in order to make patient pathways across primary and secondary care more consistent and to move more care into the community setting. It is here that telehealth and telecare will come into their own as a means to facilitate the transition.
Demonstrating the effectiveness of home monitoring of blood pressure, supporting community services such as HIV or stoma care, and promoting medical devices that offer continuous subcutaneous infusion of insulin are examples of technology implementation where a vital case can be made to these prospective healthcare commissioners. CCGs will also look favourably on management of their patients in the surgery with video links to consultants for advice, rather than sending them to outpatient services.
Clinical services that utilise new or different medical technologies will require staff who are appropriately trained and have the skills and competencies to use the equipment. This training can be provided by the medtech industry.
As ever, good information forms the basis of good commissioning and the demonstration of successful patient outcomes. Data systems in the community setting have always lagged behind their counterparts in the acute setting. Given that CCGS will need to develop services in the community, new and better IT systems will be required.
The next few months will be busy while the NHS sorts itself out at a structural level. Once the picture begins to clear, the medtech industry will need to engage with the new clinically skilled commissioners who now have the financial responsibility for making decisions about healthcare.
Dr Thoreya Swage was formerly an NHS clinician and a senior manager in various NHS organisations covering acute and primary care. She has expertise in commissioning health services and is currently working for a number of NHS organisations, including DH agencies, to develop a more commercial approach to the commissioning of healthcare.