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May we move on then to Clinical Commissioning Groups, and we have a paper on the authorisation
governance arrangements from Barbara Hakin, who I invite to introduce it. Barbara.
Thank you, Chairman. If I can take the Board members back initially to the central tenets
of the government reforms, which actually placed in the hands of partnerships of family
doctors and their practices the responsibility for the commissioning, for the planning and
then agreeing and making arrangements for services for patients and their public. These
organisations are to be called Clinical Commissioning Groups, the rationale for that being that
general practice family doctors not only have very significant relationships with individual
patients and so therefore are able to take a great deal of feedback on a day-to-day basis
about their patients’ views, but often have very intimate relationships with their populations
and their communities, and understand their needs as well. However, it was recognised
that this was quite a big ask for this group and the people who would surround and support
them, at which point the concept of the authorisation of Clinical Commissioning Groups came about,
in order to make sure that the clinical commissioners were properly and adequately supported, so
that we as a Board who had responsibility for oversight of the Clinical Commissioning
Groups could be assured on behalf of patients and the public that they had all the right
competencies, in order to make sure that they could oversee health services for patients
and ensure that patients got comprehensive, high-quality, safe services, and also take
responsibility for very significant sums of public money.
In doing so, we determined that there were six key aspects that we thought were core
to Clinical Commissioning Groups being able to take on those functions. One of these was
that they could demonstrate that they were putting patients and the public at the heart
of everything they did, and had the right mechanisms for engaging. Secondly, that they
were clinically led, and clinical issues were through and through; so they were deeply committed
to equality and safety for patients. Thirdly, that they had a sound, robust plan in order
to ensure that the services they commissioned with the public’s money were comprehensive
and met all the needs. Fourthly, that they had the broad level of competencies. Lots
of commissioning is about clinical areas, but there are also a huge range of other aspects
that support the planning of services, that support the right contracts to ensure that
providers deliver those services, and to support the monitoring of those contracts, to be absolutely
sure that patients are getting the quality of services that the public’s money is being
used to buy. One of the domains that we were looking at
was to ensure that they had the full range of competencies to discharge across those
areas. We wanted to be sure that they had the right leadership, and finally, we wanted
to be sure that they had the arrangements in place where they had to collaborate where
they needed to collaborate with one another. To commission: where they needed to collaborate
with local authorities to commission, and where they needed to collaborate with the
NHS Commissioning Board itself. I thought it was just worth reminding us,
taking us back to why we then set up an authorisation process, and the basis of the authorisation
process being those six domains. In the past, the Board has discussed the different elements
of authorisation – I think it is one of the things that we have discussed at every
Board meeting – and signed off the early stages and the agreements to the data collection
exercises and the nature of the site panels. This particular paper asks the Board to approve
the final processes in the authorisation process in order to come to the final sign-off by
the Board, so that CCGs across the country can be established; and also, the paper attempts
to give the Board the appropriate assurances that, as we make progress with the authorisation
process, it is doing what it set out to do. I think it is important to look at those final
three steps that specifically finish the process. There are two panels – and I would like
to ask the Board if they would approve the constitutions of those panels – that really
do quite a separate function. The moderation panel is there to ensure that we have a fair,
consistent and robust process across the whole country; I would use as an analogy the GCSE
examinations, or any examination, shall we say. It is absolutely critical that this process
is fair and consistent, so we need a set of processes in place to ensure that different
parts of the country are not assessed differently, or that different panels are not behaving
differently. Then – and vitally importantly – there
is a conditions panel, and this is the panel that looks at the individual CCGs rather than
at the overarching process, brings together all the evidence that comes in from the processes
that have gone on thus far, and determines whether the CCG should be authorised, and
if so, whether any conditions need to be attached. What we have at the moment is a funnel system
in order to take us through; we are helping CCGs and supporting them to be in a position
to be authorised with either ‘no’ or the minimum number of conditions.
The process is well underway, and if you remember, we have four waves. Wave one is already at
the site-visit process. CCGs can demonstrate that they meet some of the conditions that
are sitting underneath the six domains and make up the six domains through the desktop
exercise. Wave one has completed that exercise. The site visits are ongoing as we speak, and
they give CCGs an opportunity to demonstrate that they have met further competencies; but
there then will still be an opportunity for CCGs beyond that, through the process of the
conditions panel and even up to the sub-committee panel, to demonstrate that they have met the
conditions. So far, the feedback that we have from the
process has been very positive. I think that the site visits have gone well, and the CCGs
undertaking the process have said that the process has helped and has been useful in
terms of their own organisational development. Nonetheless, and notwithstanding that, there
are still 212 CCGs in total and a very significant task ahead of us to take this through to the
end-point. One other point that I would like to make
is just an understanding of the conditions that we could apply to CCGs. Plainly, for
those who are going through in the early waves, there will be some things that they simply
cannot have completed and could not complete without the majesty of time. In terms of the
plan, the natural NHS cycle and the planning process, it will be some time after their
site visits when they can put all the detail around their plans.
I think it is really important that we recognise for those CCGs that there really are two kinds
of conditions. There are those that we would absolutely expect the CCGs to be able to meet
and it was just a question of time, because they showed that they were competent and there
were other factors. I think that whilst those are really important and we will put those
in place and then have a process for ensuring that they have passed those milestones through
the operations directorate, what is really critical for the Board will be to determine
the conditions post-April 2013. That is the point at with the CCGs actually take on responsibility
for their patients’ and their population’s healthcare. It will be the nature of those
conditions that is key. I am really very happy, Chairman, to take
any questions and comments, but in essence, I am asking the Board if this is adequate
reassurance for them about the process that we are undertaking. I think that it will be
important for the Board to approve the terms of reference and the membership of the two
panels that feed into the subcommittee – the moderation and the conditions panels – as
well as asking the Board to agree to establish a subcommittee with the delegated authority
for the final decisions on the authorisation for CCGs.
Since we wrote the paper, it is really apparent, I think, as does Paul, that the Director of
Finance must also have a place on the subcommittee, so the Commission would like to ask that we
take these minutes with that as an addition, with that caveat to agree that we will establish
that subcommittee, which will have a very significant task and will be able to devote
the time and attention to look very specifically at the process that we have gone through for
authorising these individual organisations. I think the subcommittee’s role is to be
absolutely sure that the operational and executive process that has been undertaken is absolutely
robust and that they can have confidence in the outcomes.
Malcolm Grant: Thank you, Barbara. I know that one of the additional ways in which the
non-executive members of the Board propose to assure themselves is by participating in
a site visit, not as an active participant, but as an observer; and possibly on more than
one, so that we can start truly to understand what the processes are and what the evidence
is that is being presented and how rigorously it is being assessed. I think that is a very
important part of our own personal learning, and also understanding the dynamics of the
process. Let me first of all invite comments on the
paper, and then I will put the proposals to the Board. Yes, Moira.
Moira Gibb: Is the subcommittee time-limited? Barbara Hakin: It is, yes.
Moira Gibb: We should probably just make that clear really.
Malcolm Grant: We anticipate that we will meet on four occasions.
Barbara Hakin: Each of the waves will need one subcommittee meeting to assess.
Ciarán Devane: It sounds robust, just as an observation.
David Nicholson: Without boring everyone to death, I did sit in on one of these as an
observer in the way that many people I think already are doing. I did one in the East Midlands,
and there are two or three things about it. One of them is to get yourselves ready for
it being quite difficult, because you are not really allowed to intervene or speak;
so you have to keep yourself holding onto the table, and they will ask you questions
as well as you go along. Actually, I thought it was a really impressive thing. I think
that the assessors were really very good; they were experienced health-service people,
and people from outside the health service. They commented to me on the training that
they had been given; they thought that the training was really excellent and had got
them into a place where they could do it. In terms of the process itself, I think that
if we see the authorisation as a two-day visit, I think that we will misunderstand it. It
is a really powerful forcing mechanism to get people into the right place, and whilst
they were very determined to perform, nevertheless, to get to the place I thought was really impressive.
I do take the point though that on the things that they were struggling with, you could
see very quickly in the next three or four months with the information that they will
get through the planning system that they will be able to sort all of those things out.
I do think how we do that will be quite important. The other thing is that I just think we need
the opportunity to reflect all the time on this, because if there are things that we
can adjust or change or add to it as we go along, I think we should do it; so some mechanism
by which people who sit in on those subcommittees can then bring that information back to you,
Barbara, and your team, so we can tweak things to make sure that they work. That would be
a good way of doing it. I was very impressed with the CCG, I have
to say, as well. Malcolm Grant: That is without prejudice to
any decision that will be made. Ciarán Devane: I understand that they were particularly pleased
to see you. Jim Easton: I think that it is a fantastic
process. It has been organised in a really professional and inclusive way. Just to say
something about the conditions panel, because I think that there are three things about
that that are important. First, it is obviously very important to the CCG itself, about what
those conditions are. The second one is, it is kind of where the matrix comes alive, and
it is absolutely correct that, as described here, it is led through our regions, our setting
and agreeing those; but I think we need to pay continued attention to keep the link on
the issues alive. I think that is worth some further reflection.
I then think that it will be a very valuable source of insight to us, the picture of those
conditions, because I think that it will tell us a lot about how we need to support the
journey of CCGs very directly. The aggregate of those is in a sense our agenda of support.
I am therefore expecting it to tell us a lot about the capacity to be changed, about medium-term
planning, and I would imagine that it is something that as a Board we will want to use very directly
in terms of it informing the wider work of the Board and supporting the commissioning
system. That is my agenda and Bruce’s and Jane’s and Tim’s.
Malcolm Grant: Victor? Victor Adebowale: I just want to be clear,
because I have some of these visits in my diary. When we go, we take the vow of omerta,
we do not say anything; but can we feed back our thoughts? It will kill me. Can we feed
back our observations into some kind of process? David Nicholson: Definitely, yes. The little
pack will tell you what you can and cannot do.
Victor Adebowale: Afterwards, can we feed back?
David Nicholson: Yes. I do not think that we should feed back what we thought of the
individual, but the way the process operates. Victor Adebowale: Yes, that is what I meant.
Barbara Hakin: The reason for it is absolutely to protect the integrity and the fairness
of the whole system, because otherwise, somebody might have suggested that a visit at which
David was present had had either an advantage or a disadvantage. For the record, I got feedback
that he behaved impeccably, according to the rules and instructions that he had been given
as an observer. I do think that protecting the integrity of the process is really key.
If I may make one further point, Chairman, I am sure that the authorisation process has
been robust, and I am sure that it will give us a level of assurance about these organisations.
However, I think that it is important that everybody around this table and out there
recognises that these organisations will then be operating in an extremely different, difficult
environment, and I think that it would be wrong to make the assumption that authorisation
means that they will have no problems and that it will be very easy for them to undertake
what is a significant task. Malcolm Grant: This is an immensely important
set of decisions that we will be taking as a Board, because there is only one shot at
it. We have to ensure that the CCGs are as fit for purpose as they possibly can be, and
ready to perform to the highest levels possible. Function thereafter is one both of oversight
but more importantly of support. The interaction between them and the CSUs is also going to
be absolutely critical to their success. May I invite the Board to approve first of
all the constitution and the membership of the moderation panel and the conditions panel,
with the amendment that was suggested before. Then so far as the subcommittee of the Board
is concerned, there is a separate paper setting out its composition in terms of reference;
is the Board happy to approve that? We will need to appoint to it three non-executive
directors. I have initial indications of willingness, perhaps even enthusiasm, from Ciarán and
Victor, and I think a possible third place which I will consult on further. Are you happy
to authorise me to confirm those appointment, taking Chair’s action?
Naguib Kheraj: Chairman, you can take the third as well.
Malcolm Grant: Oh thank you, Naguib. I am immensely grateful, thank you. In which case,
we have the complement. Thank you. Thank you very much, Barbara, for that paper
and for I have to say the enormous amount of working that is going into making this
a rigorous and successful process. Barbara Hakin: Yes. The team doing this have
been absolutely splendid. Malcolm Grant: It shows.