An interpretation of NHS England s Primary Care Co-commissioning: Regional Roadshows questions and answers Rachel Lea, Beds & Herts LMC Ltd

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1 An interpretation of NHS England s Primary Care Co-commissioning: Regional Roadshows questions and answers Rachel Lea, Beds & Herts LMC Ltd 2. Joint Commissioning Arrangements 2.1 One option for CCGs is to undertake joint commissioning from April 1 st. This means the CCG will be jointly responsible for commissioning GP services with NHS England. Decisions about commissioning of GP services will therefore be made by a Joint Committee comprising representatives from the CCG and the Area Team. The individuals on this new committee will be accountable to their own organisations. 2.2 Once set up, the Joint Committee will agree what bits the CCG will do and what bits the Area Team will do. 2.3 If several CCGs within one Area Team are going to be doing joint commissioning, then there could be an agreement to have one Joint Committee to cover all (or some) of the CCGs, rather than a separate one for each CCG. However, this will be a local decision and must fit in with each CCG s constitution. 2.4 The Joint Committee can be set up as soon as possible. The CCG s constitution may have to be amended to allow it to be an official committee (but there is nothing to stop it being set up in shadow form before then). 2.5 The Health and Wellbeing Board will carry on as before, but may need to make some changes to its terms of reference to recognise that the CCGs are now commissioning some GP services. 2.6 It will be a local decision about whether any other organisations (apart from the CCG and the Area Team) will be on the Joint Committee. It may be appropriate to include the local authority, but there are various technicalities that would have to be addressed, and this would be a local decision. 2.7 CCGs could submit a joint application to work together. 3. Delegated Commissioning Arrangements 3.1 Another option for CCGs is to undertake delegated commissioning from April 1 st. This means the CCG will be responsible for all the commissioning decisions about GMS, PMS and APMS services that are currently carried out by NHS England. If a CCG opted for this arrangement, NHS England would delegate all the functions to the CCG, but NHS England would retain legal liability. 3.2 List closures will be one of the functions delegated to CCGs. While the CCG will be responsible for making a decision about a list closure application, as part of that decision making they would be expected to consult with the Area Team (NB this does not mean ask permission, but to give the Area Team an opportunity to comment on the application to help inform the CCG s decision). 3.3 This paragraph repeats that responsibility for all aspects relating to GMS, PMS and APMS contracts will be delegated under these arrangements. NHS England will retain full responsibility for managing the Performers List and for appraisal and revalidation. Everything else will be done by the CCG. 3.4 GMS, PMS and APMS contracts will legally still be held by NHS England (because it would require a change in the law to change this), and the CCG will contract on behalf of NHS England.

2 3.5 Your GMS, PMS or APMS contract will not be replaced by a new one. It will still be held by NHS England. The performance management of your contract will be delegated to the CCG. CCGs will be able to apply contractual sanctions and to procure new contracts. 3.6 NHS England will delegate responsibility for the practice contracts in a CCG area to that CCG and to that CCG only. If CCGs wish to work together, they can, but they can t make decisions on behalf of each other. 3.7 There will be a national template in January detailing how these functions will be delegated. 4. Managing Conflicts of Interest 4.1 New guidance on conflicts of interest has been published and all CCGs will have to read it to make sure their arrangements are sound. 4.2 The guidance sets out the structures that CCGs will have to set up to make decisions about GP commissioning. There is some flexibility in how CCGs do this (e.g. the frequency of meetings) but the main principles are that there will have to be a committee that makes decisions about the services commissioned from GPs that has more lay and executives on it than GPs, and that meets in public. 4.3 GPs must not be in the majority on this decision-making committee. The committee can also include secondary care clinicians, nurses and/or GPs from outside the CCG. 4.4 The purpose of this committee is to give public assurance that decisions are not taken by the GPs who will benefit (directly or indirectly) from those decisions. 4.5 CCGs have to manage conflicts of interest and therefore have to make sure they have arrangements in place even if this means setting up yet more committees. If the CCG is doing Joint Commissioning (rather than Delegated) then the Joint Committee will be the decision-making committee. CCGs are advised to refer to the National Audit Office report on out of hours services. 4.6 If the CCG s existing arrangements meet the guidance, then they can continue rather than set up new committees. 4.7 The difficulties of all this are recognised, and the impact that this may have on GPs continued involvement in commissioning. NHS England is working on this. 4.8 Decisions made by the Decision-making Committee do not need to be ratified by the Governing Body of the CCG. 4.9 The Governing Body of the CCG (which has a clinical majority) could also function as the Decision-making Committee if all the GPs exclude themselves from the meeting when decisions about GP services are being made Conflicts have to be declared, and how they are then managed will depend on the nature of the conflict Healthwatch must have a standing invitation to the Decision-making Committee. Their attendance is not mandatory (i.e. they are not part of the quorum) Local authority employees can be part of a CCG s Governing Body, but elected members cannot. (this point is not related to co-commissioning).

3 4.13 CCGs will probably have to change their constitutions to meet the conflicts of interest guidance, but won t be able to have these changes ratified by their Governing Body before the deadline of January 9 th. So they can send in draft changes and get them signed off later. 5 Changing Co-commissioning Arrangements 5.1 Changing from Joint Commissioning to Delegated Commissioning can only be done annually rather than in-year. 5.2 NHS England hasn t yet thought about the other primary care services (pharmacy, dentistry and optometry) or whether a CCG with delegated authority can take these on in due course or will have to go through another approval process. They will think about this during 2015/ CCGs can move to take on Joint Commissioning during 2015/16 if they aren t ready to go in April. (Unclear how this fits in with 5.1 above). 6 Finance 6.1 CCGs will not get any more money to take on Joint or Delegated Commissioning. They will have to pay for this from within their existing running costs. 6.2 If CCGs take on Delegated Commissioning they will be taking on the budget relating to the GMS, PMS and APMS contracts. CCGs have to make a 0.5% surplus on their entire budget which will include this primary medical care element. 6.3 Nationally, NHS England is looking at allocations and uplifts this will be done nationally, not locally. 6.4 CCGs that are challenged financially won t be excluded from being able to do co-commissioning; NHS England will look at their circumstances and plans on an individual basis. 6.5 If people have been told or heard that CCGs that are in financial difficulties will not be allowed to do co-commissioning, then NHS England wants to know as that is not the official line. 6.6 Area Teams are being asked to provide financial information to CCGs 6.7 The allocation is what is given to the CCGs, but they have to put some aside for contingencies and planned underspends as per the national statutory requirements, similar to the answer in 6.2. They won t be given any more in order to meet this surplus. 6.8 (This is a question about what financial information the CCGs will get. The CCG s finance team will understand this and the actual figures are expected any day.) 6.9 Area Teams know what is currently being spent on GMS, PMS and APMS and can share that with CCGs Primary medical care budgets are not ring fenced As no budgets are ring fenced, CCGs can use underspends in one area (e.g. the GMS budget) to offset overspends in other areas CCGs will have flexibility (within business rules) to change incentive schemes. CCGs should discuss any plans or decisions about changes to local incentive schemes (e.g. QOF) with the LMC.

4 7 Premises, Public Health and other primary care services 7.1 Running costs for premises will be included in the budgets delegated to CCGs (if they take on Delegated Commissioning). More work is being done on this nationally. 7.2 NHS England is looking at public health services that are commissioned from GPs, as well as some other things such as specialised services. There is a group called Joint CCG and NHS England Primary Care Co-Commissioning Programme Oversight Group that is considering all these things. 8 Resources 8.1 If the Area Team doesn t have the capacity to support local arrangements (e.g. if each CCG in an area wants a separate Joint Committee) then the Regional office of NHS England will have to help. At this stage, NHS England doesn t know whether or not Area Teams will have the capacity or what the impact will be. 8.2 Area Team staff will have to work more closely with CCGs (unclear about what impact this will have). 8.3 Staff will not be transferred from NHS England to CCGs. There will be no national steer about how Area Teams and CCGs will work together; it all has to be worked out locally. 8.4 CCGs that take on Delegated responsibility have to have access to a fair share of the Area Team s primary care commissioning staff (but there are no details of what this means it all has to be worked out locally). Area Teams have to retain enough staff to deliver the remaining obligations. 8.5 Again, it will be locally agreed how Area Team staff will be shared between CCGs. 8.6 Area Team staff will be involved in conversations about how they work with CCGs. 8.7 If the Area Team and CCGs can t agree, they should go to the NHS England Regional office for advice. 9 Application Process 9.1 The deadlines for CCGs to submit their applications to NHS England (9 th January for Delegated Commissioning and 30 th January for Joint Commissioning) cannot be moved, but CCGs can submit draft plans as long as they provide information about how they are going to get it all completed by 31 st March (but see point 9.6 below). 9.2 If CCGs don t have time to submit an application for Delegated Commissioning then they can submit a plan for Joint Commissioning. NHS England says that CCGs should know about most expenditure already and already be working up plans with Area Teams. 9.3 NHS England expects CCGs to engage with their membership about co-commissioning. It would be good practice to talk to others e.g. Healthwatch. 9.4 NHS England expected CCGs to have started engaging with members and others when they first submitted their expressions of interest back in May, so this should now be near completion. They would expect CCGs to continue to engage with their members. 9.5 CCGs have to include primary care spending plans in their application if they are planning to take on Delegated Commissioning.

5 9.6 The deadline of 9 th January for Delegated Commissioning is absolutely fixed but there could be some room for negotiation for Joint Commissioning proposals in exceptional circumstances and with agreement with the Area Team and the Regional office. 9.7 CCGs should contact their Area Team for legal advice if they need it. 10 Constitution submission 10.1 Requests from CCGs to amend their constitutions have to be sent to the Regional office of NHS England. There are tight deadlines and processes for doing this. NHS England will accept draft amendments, and they must all be approved and signed off by the time co-commissioning starts in April NHS England also wants to know how the CCG has engaged over its constitutional amendments. 11 Assessment and approval process 11.1 NHS England s Regional Directors will decide who sits on the panel that will assess applications for co-commissioning. Members will include representatives from the Regional Office and the Area Teams, plus a CCG lay member Each application will be considered on its merits If CCGs want to work together, but one of them is in special measures, NHS England would consider the application and pay particular attention to financial governance arrangements (don t understand this one) 12 Assurance 12.1 NHS England is still working on the assurance framework (in discussion with CCGs) NHS England is still working on how they might intervene if something goes wrong (as above 12.1) 12.4 NHS England isn t clear yet what will happen if a CCG doesn t secure a high level of quality of primary medical care services other than that the Area Team will want to discuss it with the CCG. 13 Appeals 13.1 NHS England is still working on risk sharing issues If several CCGs work together and have a joint decision making arrangement, then their terms of reference should specify how decisions are made. NHS England points out that big committees are more likely to have their decisions challenged by patients and the public, as each CCG has a statutory duty to engage their local population. (Also see paragraph 3.6 above which suggests that each CCG is responsible for its own decisions) Under joint arrangements, either party can choose to terminate the agreement and take the functions back. (NB it isn t clear if this is talking about joint arrangements between CCGs, or Joint Commissioning between the CCG and the Area Team).