Www.england.nhs.uk Introduction to primary care co- commissioning.

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Introduction to primary care co-commissioning

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• Welcome and thank you for coming today. We hope you will find it a really useful day which will help you to implement co-commissioning arrangements locally.

• So why co-commissioning?• CCGs have consistently indicated that they wish to assume

greater responsibility for the commissioning of primary care services;

• CCGs have frequently expressed frustrations about fragmentation of the current commissioning system;

• We know co-commissioning will help to align the commissioning system and could stabilise and sustain primary care – and enable us to take advantage of the New Deal for general practice that is signalled in the NHS Five Year Forward View.

Welcome and introduction


• The overall aim of co-commissioning is to develop better integrated out-of-hospital services based around the diverse needs of local populations.

• Co-commissioning could potentially lead to a range of benefits for the public and patients, including:• Improved access to primary care and wider out-of-hospitals

services, with more services available closer to home;• High quality out-of-hospitals care;• Improved health outcomes, equity of access, reduced

inequalities; and• A better patient experience through more joined up services.

Intended benefits for local populations


• Co-commissioning is one of a series of changes set out in the NHS Five Year Forward View.

• The Forward View sets out the need to break down traditional barriers in how care is provided. It calls for out-of-hospital care to become a much larger part of what the NHS does, and for services to be better integrated around the patient.

• Co-commissioning is a key driver of this by enabling greater collaboration between commissioners across local health economies and wider geographical and organisational footprints.

• The Forward View encourages greater innovation in service and delivery models in recognition that although the NHS is a national health service, one size does not fit all when it comes to diverse demographics and local need. It sets out a number of new models of care including multispecialty community providers, integrated primary and acute care systems, and integrated approaches to urgent and emergency care.

• New models of care will be much easier to deliver by having commissioning responsibilities for primary and secondary care in the same place.

• Furthermore, co-commissioning will give GPs a greater say over the development of new services and models of care for their local communities.

• The Forward View also sets out a commitment to invest more in primary care over the next five years :

• Through co-commissioning CCGs will have the option of more control over the wider NHS budget, enabling a shift in investment from acute to primary and community services.

The future vision


• This event builds upon the Next steps towards primary care co-commissioning document, which was published on 10 November 2014.

• We know that many CCGs felt there was not enough information on which to base the May ‘expression of interest’. The next steps document aims to give that information, and we have tried to make the process as simple and straightforward as possible.

• Through the primary care co-commissioning programme oversight group, we have worked with NHS England and NHS Clinical Commissioners to agree the approach set out in this document.

• The oversight group is co-chaired by Dr Amanda Doyle (Chief Clinical Officer, NHS Blackpool CCG and Co-chair, NHS Clinical Commissioners) and Ian Dodge (National Director: Commissioning Strategy, NHS England).

Next steps towards primary care co-commissioning document


• In developing the co-commissioning approach, we have agreed with CCGs that there will be:

• Three standard models for the co-commissioning of primary care for reasons of governance and administrative efficiency;

• National principles for the deployment of administrative resources to support the implementation of co-commissioning;

• A national, robust approach to the management of conflicts of interest to mitigate risk to both CCGs and NHS England; and

• Local flexibilities for contracts and incentives schemes to enable innovation and optimal local solutions.

Key policy issues

Greater

involvement in primary care

decision-making

Joint commissioning arrangements

Delegated commissioning arrangements


• Conflicts of interest need to be carefully managed within co-commissioning. Whilst there is already conflicts of interest guidance in place for CCGs, this will be strengthened in recognition that co-commissioning is likely to increase the range and frequency of real and perceived conflicts of interest, especially for delegated arrangements.

• A national framework for conflicts of interest in primary care co-commissioning will be published as statutory guidance in December 2014. This is being developed in partnership with NHS Clinical Commissioners and with formal engagement of Monitor and HealthWatch.

• The new conflicts of interest guidance will include a strengthened approach to:• the make-up of the decision-making committee: the committee must have a lay and

executive majority and have a lay chair;• national training for CCG lay members to support and strengthen their role;• external involvement of local stakeholders: the local Health Watch and a local authority

member of the local Health and Well-being Board will have the right to serve as observers on the decision-making committee;

• register of interest: the public register of conflicts of interest will include information on the nature of the conflict and details of the conflicted parties. The register would form an obligatory part of the annual accounts and be signed off by external auditors;

• register of decisions: CCGs will be required to maintain and publish, on a regular basis, a register of all key procurement decisions.

• a requirement for GP’s to make public their earnings

Conflicts of interest management


• It will be important that we review and share learning from the implementation of co-commissioning arrangements in real time in order to support CCGs’ continuous development and improvement. We will evaluate the following:

• what is and is not working;• any unforeseen perverse incentives and system blockages; and• examples of good practice.

• In addition, we are exploring options on how best to do the following:

• provide technical support where required;• enable the dissemination of ‘lessons learned’ and supporting a network of

practitioners to problem solve and share learning and experiences; and• provide a web-based interactive platform for exchange and ideas.

Development support


• To set out the vision for the future as we move towards a place-based commissioning approach.

• To provide an opportunity for CCGs and area teams to raise any questions they may have about primary care co-commissioning and the impact of the changes.

• To provide technical advice, in the following areas, to support the implementation of co-commissioning arrangements:• the governance frameworks for joint and delegated arrangements;• conflicts of interest management; • financial arrangements and resources; and• the timeline and approvals process.

• To offer a further opportunity for area teams and CCGs to work together on their joint proposals, if they so wish.

Purpose of the day

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Primary careco-commissioning workshop:Legal plenary


• Same overall framework applies to all three models of co-commissioning

• Focus on options 2 (joint commissioning) and 3 (delegated commissioning)

• Starting point is the National Health Service Act 2006 (as amended by the Health and Social Care Act 2012)

• Supplemented by:• Secondary legislation such as regulations;• Public law obligations; and • Guidance.

Overview of legal framework


• NHS England’s statutory duties • Section 1H of the NHS Act• Section 13O and section 13P of the NHS Act • Section 83 of the NHS Act • Section 91 of the NHS Act • Plus regulations

• Ability to enter into arrangements with CCGs, including delegated arrangements (section 13Z)

• CCGs and NHS England can now establish joint committees (sections 13Z, 14Z3 and 14Z9 of the NHS Act, as amended by the LRO)

• Procurement • National Health Service (Procurement, Patient Choice and Competition) (No. 2)

Regulations 2013• Monitor guidance • Future NHS England guidance

PMS commissioning – NHS England


• Establishment of joint committee • Governance• Membership, including non voting attendees• Ability to delegated CCG functions to joint committee (section

14Z9)• Benefits of joint committee approach

• Integrated working

• Conflicts of interest

Joint commissioning


• Suite of documents• Delegation – formal public law instrument• Terms of reference for primary care commissioning committee• Delegation agreement – detailed arrangements as agreed

between NHS England and the CCG in question

• NHS England reserved functions and overall liability

• Conflicts of interest management • Statutory guidance to be issued under section 14Z8 (revised

version of the Code of Conduct)

Delegated commissioning

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Primary careco-commissioning workshop:Finance plenary

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• Primary Care Allocation 2014/15 and use of target formula

• Differential Uplift based on Distance From Target

• Key allocative policy:- minimise ring-fence

• “The one big pot approach to allocations”

• Request for actual and target at CCG level

Introduction:- How did we get here?

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• Allocative nightmare:- lets face it we struggle with disaggregation.

• Start point:- what is spent and where.

• Baseline return from Area Team for 2014/15:- a fixed point.

• Recurrent Allocation, not necessarily “available spend”

…..and co-commissioning


• By 30th November to publish the baseline (2014/15) recurrent allocation by CCG and the split to GP services

• We are working on the assumption of “no surprises” and assuming area teams have been discussing this with CCGs. It will be based on the October submissions made by area teams.

• With confirmation of CCG allocations indication of the primary care allocation by CCG with notional amount available for co-commissioning (mid-late December)

The aim


• This is an allocation not an expenditure budget

• Public Health “non-recurrent” transfer

• Business Rules for 2015/16 not yet confirmed will impact on the amount available for expenditure.

• Therefore we have a risk and a challenge

The Issues


What comes first the business rules or the allocation?


• Headroom, contingency and surplus

• Business rules will be consistent for primary care, however administered

• The delegation of an allocation will come with the requirement that these rules will be adhered to.

Business Rules


• DDRB recurrent saving in 2014/15 currently in recurrent baseline will be reversed for 2015/16

• Uplift for 2015/16 for all primary care including GP services will not be confirmed until mid-December. (this is not just a primary care issue).

• DDRB for 2015/16 will announce after the allocation is confirmed. The impact of this on allocation and spending power will be assessed as part of planning.

Allocation


• For joint arrangements allocations to be agreed locally. (confirmation of arrangements).

• For full delegation approval of sum will be require CFO sign off.

• Expectation CCG in full delegation will be able to demonstrate compliance with business rules

• The IFSE elements of this are mind blowing (and best discussed another day!)

Finance Element of Delegation

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Primary careco-commissioning workshop:Technical plenary


• To be conducted openly and transparently and contain no surprises

• An opportunity to review preferred co-commissioning arrangements with members and local stakeholders

• CCGs and area teams to work together on what they would like to do. To jointly complete a proforma should they wish to assume joint or delegated arrangements

The Approvals Process


Greater Involvement in Primary Care Co Commissioning

• No formal approvals process

• Periodic surveys to provide an opportunity to feedback on local arrangements


Joint Commissioning

• CCGs and area teams to complete proforma and supporting information for joint arrangements 30 January 2015

• Supporting information includes the proposed governance structure and constitution amendment request

• Regional moderation panels early February 2015 – panels will be regional and area team representatives from all relevant disciplines

• Arrangements implemented by 1 April 2015


Delegated Commissioning• CCGs and area teams to complete proforma and

supporting information for delegated arrangements Noon 9 January 2015

• Regional moderation panels mid January 2015 – panel will be constituted from area and regional colleagues from all relevant disciplines

• National moderation panel (late January) will make recommendations to a new NHS England committee

• Committee sign off of delegated proposals in Feb 2015• Detailed plan for spend included in the planning

template


Delegated Commissioning (contd)• Where proposals are not recommended for approval,

an appropriate plan will be developed between the CCG and area team, supported by regional teams, to further develop proposals or establish joint arrangements for 15/16

• CCGs will sign a legally binding agreement to confirm the detail of how NHS England will delegate its general practice functions to CCGs

• Funds transferred 1 April 2015


Changes to a CCG Constitution• Proposals for joint and delegated commissioning

arrangements will probably require an amendment to a CCG’s constitution

• If this is the only constitution amendment request it can be submitted with the proposal (so delegated commissioning 9 January, joint commissioning 30 January). All other constitutional amendment requests should have been submitted through the normal route by 6 January 15

• Constitution amendments that only relate to co-commissioning should be emailed to [email protected] as well as to region

mailto:[email protected]


Governance Structures

• NHS England has developed governance frameworks on behalf of CCGs including a template constitution amendment and template terms of reference

• Template documents can be amended to reflect local arrangements

• The detail of governance arrangements to be discussed and agreed locally


Changing a co-commissioning arrangement from 15/16 onwards

• There is great variation in appetite to take on primary care commissioning and not all members of all CCGs will be ready to go to this timetable

• CCGs should discuss plans to change their co-commissioning with their area team. New proposals for joint committees can be considered in-year through 15/16, and joint committees can consider progressing to joint budgets

• Conversely if things are not going well, arrangements can be rolled back by mutual agreement. This should be discussed through the assurance process


• Delegated arrangements will be monitored as part of the CCG assurance process

• NHS England is co-developing a revised approach for the 15/16 CCG assurance framework

• If you would like to be involved in the wider development of the assurance framework please contact [email protected]

Ongoing Assurance



Summary

Delegated arrangements – noon on 9 January, with both CCG and NHS England sections complete – to [email protected]

Joint committee proposals – 5pm on 30 January, with both CCG and NHS England sections complete – to [email protected]




Please visit the primary care co-commissioning webpage on the NHS England website:

www.england.nhs.uk/commissioning/pc-co-comms

PLEASE:• Complete the evaluation form• Leave your email address on the form if you think we

may not have it. All delegates will receive a copy of the slides by email tomorrow

Co-commissioning webpage

http://www.england.nhs.uk/commissioning/pc-co-comms

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Primary care co-commissioning

Closing remarks

Www.england.nhs.uk Introduction to primary care co- commissioning.

Documents

Transcript of Www.england.nhs.uk Introduction to primary care co- commissioning.