Croydon, Kingston, Merton, Richmond, Sutton, Wandsworth CCGs and NHS England
Exploring an option to move towards delegated
commissioning
June 2015
1. Introduction
This paper provides each SWL CCG Governing Body with a range of information on
Delegated Commissioning for primary care. It includes:
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Section 1: Introduction
Section 2: Context
Section 3: The opportunity for delegated commissioning: including differences from
joint commissioning, what this would involve, opportunities and risks
Section 4: Timeline and next steps for SWL CCGs
The deadline for submission of the Delegation proforma has been set by NHS England as the
2 October 2015. This means that final decisions regarding the option to move to delegated
commissioning, will need to be approved in each CCG’s September 2015 Governing Body.
As a result, CCGs are asked:



to consider the points set in this paper and the option to move to individual CCG
delegated commissioning.
to discuss in July Governing Body meetings and determine if your CCG should begin
work with NHS England London Regional Team to prepare the information required
for the Delegation proforma.
to inform SWL Collaborative Commissioning the outcome of your discussion in July,
so that the implications for the SWL Joint Committee for Primary Care CoCommissioning can be discussed.
2. Context
Approval to establish joint commissioning arrangements in SWL was given in March 2015.
The Joint Committee was established for the CCGs to work together with NHS England
London Regional Team and representatives from HealthWatch and the Health and Wellbeing
Boards, to develop capacity, capability and expertise to commission general practice. The
inaugural meeting of the South West London Joint Committee for Primary Care
Commissioning (Joint Committee) happened on the 14 May 2015 and the next meeting is
scheduled for the 9 July 2015.
The aim of primary care co-commissioning is to ensure improvement at scale and pace in
developing “place-based” commissioning and joined up care pathways; in line with the SWL
5-Year strategic plan and with the ability to manage potential risks such as conflicts of interest
and resource pressures. It provides the opportunity to align primary care development
initiatives, contracting and investment for out-of-hospital care with general practice and
primary care. It will also drive the development of new models of care set out in the NHS Five
Year Forward View on the assumption that integrated commissioning is a key enabler of
integrated provision.
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Report to CCGs on an option to move towards delegated commissioning
3. The opportunity for delegated commissioning - what will delegated
commissioning involve?
An overview of the differences between Level two: Joint Commissioning arrangements and
Level 3: Delegated Commissioning arrangements is provided at Figure 1.
Figure 1
Delegated commissioning offers an opportunity for individual CCGs to assume full
responsibility for commissioning general practice services (with NHS England retaining the
residual liability for the performance of primary medical care commissioning) including the
following functions:
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GMS, PMS and APMS contracts (including the design of PMS and APMS contracts,
monitoring of contracts, taking contractual action, such as issuing branch/remedial
notices, and removing a contract);
Newly designed enhanced services (“Local Enhanced Services (LES)” and “Directed
Enhanced Services (DES)”);
Design of local incentive schemes as an alternative to the Quality and Outcomes
Framework (QOF);
The ability to establish new GP practices in an area;
Approving practice mergers; and
Making decisions on ‘discretionary’ payments (e.g., returner/retainer schemes).
A summary of the primary care functions that joint versus delegated commissioning have
responsibility for is provided in Table 1.
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Report to CCGs on an option to move towards delegated commissioning
Table 1: Summary of co-commissioning functions
Primary Care Function
Joint Commissioning
Responsibility
Delegated Commissioning
Responsibility
1.
General practice
commissioning
Jointly with Area Team
Yes
2.
Design and implementation
of local incentives schemes
Subject to joint
agreement with Area
Team
Yes
3.
General practice budget
management
Jointly with Area Team
Yes
4.
Complaints management
Jointly with Area Team
Yes
5.
Contractual GP practice
performance management
Jointly with Area Team
Yes
6.
Medical performers’ list,
appraisal, revalidation
7.
Pharmacy, eye, health and
dental commissioning
No
Potential for involvement
in discussions but no
decision making role
No
Potential for involvement in
discussions but no decision
making role
A more detailed outline of issues to consider for delegated commissioning is presented in
Table 2; this is on the basis of a report from the Royal College of General Practitioners and
NHS Clinical Commissioners. In this report issues for consideration regarding delegated
commissioning were presented in the following areas:
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
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Funding to pay for new/improved/enhanced general practice services
Relationship to the membership across the CCG accountability & influence
Practice contract management
Support to undertake the work (people /£)
Ability to re design service delivery models including integration of care
Managing potential conflicts of interest
Governance
Patient engagement
Assurance of co-commissioning arrangement
Operational arrangements for transacting commissioning arrangements
Further information on the recommendations for governance, membership, decision making
process, and voting process for delegated commissioning is provided in Appendix 1.
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Croydon, Kingston, Merton, Richmond, Sutton, Wandsworth CCGs and NHS England
Table 2: Issues to consider - Delegated commissioning
Funding to
pay for new
/improved/
enhanced
general
practice
services
Opportunities:
Local not central determination of change, some potential for place based
budgets.
Opportunity for CCGs to stop the instability being caused by various
reviews and enable CCGs to invest equitably in primary care.
Support to
undertake the
work (people
/£)
Opportunities:
CCGs will have access to the people across the London Region Team
footprint.
Locally determined approach to staff resourcing.
Risks:
CCG may find that the support that comes from NHS England is not
enough to fulfil the full demand of commissioning activity and day to day
management.
Complete control over how the primary care budget is spent. i.e. CCGs
can develop locally designed incentive schemes, which must be consulted
with the LMC and ensure an outcome focus.
Risks:
Additional funding put in to support general practice may place other areas
of CCG commissioned care under pressure.
Relationship
to the
membership
across the
CCG
accountability
& influence
Practice
contract
management
Risk to reduction in total size of budget delegated.
Opportunities:
Performance management of general practice individuals and revalidation
will be retained by NHS England, but improved ability to influence
developmental support to primary care.
Risks:
Performance management (even through a quality improvement lens) sits
with the CCG and this could risk the membership ethos unless particular
attention is given to how this will be managed.
Opportunities
CCG can have developmental relationship with member practices. Have a
lever in relation to poor performance/practice. CCGs in control of how
contract management function is executed and can really push it through
the quality improvement lens.
Ability to re
design service
delivery
models
including
integration of
care
Managing
potential
conflicts of
interest (COI)
Opportunities:
Ability to make redesign decisions across a portfolio of providers and so
across pathways of care tailored to local need and explicit regarding
federation working.
Opportunity to be more patient focused in commissioning.
Risks:
CCGs are accountable for the decisions they make and require
transparency of process as well as the engagement and support of
member practices, the public and stakeholders.
Opportunities:
Need to review processes and decision making to ensure they are robust
and transparent.
An opportunity to improve transparency in decision making.
Quality improvement will be very much peer led and driven and this may
mean that member practices are more likely to respond / accept CCG
action/decision making.
Risks:
Will increase perceived COI in relation to the commissioning of services
from member practices and federated practices.
NHS England ultimately remains the contract holder, and NHS England
will need to be assured as to how the CCG is taking decisions in this area.
A back stop appeals process if agreed with NHS England, may help with
this in guarding against judicial reviews.
Potential risk to CCGs in the probity of their decisions if governance
arrangements are not robust.
Risks:
Potentially more bureaucratic processes to go through to assure and
demonstrate transparency, and need to ensure CCG is still able to take
decisions should all member practices be affected.
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Report to CCGs on an option to move towards delegated commissioning
CCG can be accused of policing practices (with its contract levers/
removal powers), may lead to serious damage to its reputation if this is not
executed well.
Some added cost implications though tightened governance
arrangements, which will require additional lay, secondary care doctor
and nurse member input.
The impact of no NHS England involvement in performance management
may lead to a gap in primary care performance information across CCGs
and loss of organisational memory and input at London level.
Governance
Although NHS England remains the contract holder, CCGs are acting as
agents of NHS England and therefore will be taking decisions about levers
/ sanctions even though NHS England would also retain residual liability.
Opportunities:
Opportunity for CCG to review and revise their governance arrangements
including the constitution and secure improved membership engagement.
This is likely to result in strengthened approaches to CCG governance.
Risks:
CCG is accountable for commissioning to its public and clinical peers.
Some risk that the governance processes and procedures are exposed to
challenge/appeal.
Assurance of
Cocommissioning
arrangements
by NHS
England
Patient
Engagement
Risks:
CCG is accountable to its population in relation to decisions around the
commissioning of general practice. This is a significant undertaking and
any changes to practice contracts/design must engage the public.
Risks:
NHS England may direct a CCG to act, where a CCG fails to secure an
adequate supply of high quality primary medical care.
If the CCG is directed in this way, this could affect the CCGs desire to
commission in this fully delegated form, and the resources to meet this
direction would need to come from the CCG’s resources.
Increased resources will be required around governance, including
extensive stakeholder engagement, establishment and running of a
primary care commissioning panel and scrutiny processes. CCG will need
to update its constitution and consult it with the LMC.
CCGs will be responsible for a broader range of functions including
complaints management and therefore needs to ensure processes set up
enable this within their broader governance processes.
Opportunities:
Opportunity for CCG to meaningfully engage with the local public about
the totality of expectations for general practice the out of hospital care
offer, and wider system integration.
Opportunities:
Assurance of primary and secondary care commissioning is together so
enables a rounded and mutual approach to be adopted by NHS England.
NHS England’s assurance of delegated commissioning may be
undertaken in such a way (i.e. top down and interventionist) that it
actually limits a CCGs actual power to make the right decision for its
population.
Operational
arrangements
for transacting
commissioning
arrangements
Opportunities:
Maximise influence on the transactional elements and ways of working
between staff and practices.
Ability to change the way in which the transactional elements work, such
that they operate as efficiently and effectively as possible.
Risks:
CCGs may find themselves with competing priorities over use of the NHS
England team available to support joint and delegated commissioning.
Dealing with public appeals and concerns may take CCG resource away
from commissioning.
If insufficient resource CCGs may need to direct other key CCG staff to
pick up functions, for eg complaints handling and transactional contract
issues, and may put pressure on CCG’s ability to deliver on the range of
responsibilities.
“The risks and opportunities for CCGs when co‐commissioning primary care: Things to consider when making your decision”, Royal College of General Practitioners and NHS Clinical
Commissioners, 1st December 2014. The full paper is available at the link, file:///C:/Users/905038/Downloads/Risks%20and%20opportunities%20doc.pdf
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Croydon, Kingston, Merton, Richmond, Sutton, Wandsworth CCGs and NHS England
4. Timeline and next steps for SWL CCGs
Overview of the NHS England approval process timeline for Delegated Commissioning
“Primary care co-commissioning submission and approval process for 2015/16”, NHS England, Publications
Gateway reference: 03515
In light of the NHS England approval process set out above (submission 2 October 2015),
CCGs are asked to/should be aware of:
Next steps for CCGs

CCG Governing Bodies to consider and discuss the option to move to delegated
commissioning at July Governing Body meetings (please see Appendix 2 for CCG
GB dates). If individual CCGs decide to progress with delegated commissioning, it
is recommended that CCG preparatory work is undertaken to complete the
delegation approval documents as soon as practicable.

Work with NHS England London Regional team to agree support/resource on
commissioning arrangements.

NHS England plan to issue updated submission documents for 2015/16 in July. At
this point it is not clear if these will vary significantly from those which were
required in 2014/15 and included (links to these are included in Appendix 3):
o Conflict of interest process in accordance with statutory guidance
o Financial profile and plans for change
o Meeting statutory and business planning requirements including Terms of
Reference, constitutional amendments, governance structures, membership

Throughout this period of consideration and discussion, each CCG should engage
with members and consult regarding an option to move to delegated
commissioning.

The final delegation proforma template must be submitted by midday Friday 2
October 2015 to the NHS England London Regional Team – this will require CCG
Governing Bodies to approve a delegated commissioning submission in September
Governing Body meetings.
Please note

Delegated arrangements will also require an amendment to the CCGs constitution. The deadline for
constitution amendment approvals would be the go-live date of 1 April 2016, when all agreements and
documentation must be in place. Receipt of the Delegation from NHS England will also need to be
acknowledged prior to the go-live of delegated commissioning arrangements.
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Appendix 1
Croydon, Kingston, Merton, Richmond, Sutton,
Wandsworth CCGs and NHS England
Overview of NHS England (London)
Draft Operating Model (v5) - Delegated
Commissioning
Croydon, Kingston, Merton, Richmond, Sutton and Wandsworth NHS Clinical Commissioning Groups and NHS England
‘Working together to improve the quality of care in South West London’
Croydon, Kingston, Merton, Richmond, Sutton,
Wandsworth CCGs and NHS England
Decision making in Delegated Committee
•
Delegated commissioning is granted on an individual CCG basis, therefore each CCG will be
required to have a Delegated Committee and determine locally the associated structure,
governance and decision making.
•
There are several key principles, such as the requirement for there to be considerable
engagement between NHS England and the CCG, outside of the committee. Even in delegated
commissioning it is likely that the CCG will want to seek out guidance and support from NHS
England.
•
High level process flows have been created to demonstrate how decisions might be made under
co-commissioning. The detailed processes and the standard report templates can be found in
the NHS England publication “Operating Model: Co-commissioning of Primary Care v5”. Those
processes relating to delegated commissioning detailed in this report, are included hereafter.
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Croydon, Kingston, Merton, Richmond, Sutton,
Wandsworth CCGs and NHS England
Other decision-making processes – finance and strategy
•
•
For Delegated Committees, NHSE will produce the same report, and the Delegated Committee
will again be responsible for maintaining financial balance.
However, importantly, for Delegated Committees, a monthly journal will transfer costs of
delegated functions to the CCG ledger from NHSE, and the CCG will be responsible for their own
reporting, and their own management accounting of their primary care costs. The CCG may also
make further queries of NHSE, to support this process. Management accounting activities will
likely include, but not be restricted to:
– Month end procedures
– Accruals, prepayments, and any payments additional to those in the financial plan
– The production of monthly & quarterly CCG management reports at GP practice or locality
level to ensure robust financial forecasts and analyse variances to ensure they are
explained
– Practice list size analysis by CCG locality for GM/system report downloads
– Quarterly forecasting on CQRS
– Additional year end tasks including working papers and support to AOB process
– Liaise with internal and external audit as required.
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Section 2.3.5 - “Other decision-making processes ”, Operating Model: Co-commissioning of Primary Care v5, P.13
Croydon, Kingston, Merton, Richmond, Sutton,
Wandsworth CCGs and NHS England
Other decision-making processes – finance and strategy
Process map showing financial processes (Process 2)
Delegated Comm.
CCG considers report
and puts
recommendations to
Delegated Comm.
To secure financial balance. Delegated
Committee makes decisions based upon the
financial reports and recommendations from
CCG/ CCGs. Also ensures financial systems are
in place to secure this.
Please note: the information regarding the process for Joint co-commissioning is included only for information processes
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Section 2.3.5 - “Other decision-making processes ”, Operating Model: Co-commissioning of Primary Care v5, P.13
Croydon, Kingston, Merton, Richmond, Sutton,
Wandsworth CCGs and NHS England
Meeting Agendas
It will be important for each CCG and NHS England to engage ahead of meetings, particularly in cases
where a particularly significant matter is on the agenda for discussion. This may involve the need for
additional meetings, or for information from NHS England to inform thinking on significant matters.
This will be particularly important for delegated commissioning, where NHS England will not be
participating in the committee discussion.
Each Committee should set out how this engagement will take place, as well as when, in the
standard meeting process, submissions will be accepted for discussion at each meeting.
In general, clear and active engagement with NHS England, as well as the Committee sub groups, will
help inform the content of the agenda we expect that agendas are likely to have the following
components:
• Standard agenda items, which might involve items that can be expected at each meeting, such
as an overview of finance and performance reports.
• Work-plan items, such as a review of the annual budget or developing a Primary Care Strategy,
which is determined by the known upcoming work.
• Any other items, which could include submissions from NHSE, sub groups, and the CCG.
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Croydon, Kingston, Merton, Richmond, Sutton,
Wandsworth CCGs and NHS England
Governance and Membership in Delegated Committees
Committee constitution
While much of the decision-making processes will be determined by Committees, the constitution of the
Committees themes have been set by NHSE, as a condition of co-commissioning.
The following are the criteria for a Committee:
Level Three: Delegated Committee
•
Committee is made up entirely of CCG members (NHS England will not be members of the board).
•
The Chair and Vice Chair of the committee are CCG Lay Members.
•
There is a secretary, responsible for minutes, actions, the agenda, and reporting back Committee decisions to the CCGs.
•
NHS England will also have access to the minutes etc from the board for assurance purposes, and all of these
documents will also be publically available on CCG websites.
Figure 9: Committee and Joint Committee constitution
Other Committee attendees
In the interests of transparency and the mitigation of conflicts of interest, a local HealthWatch representative and a
local authority representative from the local Health and Wellbeing Board will have the right to join the joint
committee as non-voting attendees. This will help to support alignment in decision making across the local health
and social care system.
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Section 3 - “Governance and People”, Operating Model: Co-commissioning of Primary Care v5, P.16
Croydon, Kingston, Merton, Richmond, Sutton,
Wandsworth CCGs and NHS England
Voting in the Delegated Committee
Assurance
NHS England will have access to the minutes etc. from a delegated committee and notice of committee decisions,
for assurance purposes. In cases where the statutory objectives of NHS England might be undermined, following
the decision of a delegated committee, these concerns would have to be determined and amended retroactively.
In delegated commissioning, where a committee fails to secure an adequate supply of high quality primary medical
care, it remains NHSE’s right to direct the CCG to act. Equally, Monitor may direct a CCG or a CCG and NHSE to act,
in cases where committees are found to have breached public procurement regulations, or statutory guidance on
conflicts of interest.
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Section 4.3 - “Voting process”, Operating Model: Co-commissioning of Primary Care v5, P.17
Croydon, Kingston, Merton, Richmond, Sutton,
Wandsworth CCGs and NHS England
Voting Process in a Delegated Committee
Please note, NHS England’s objectives must continue to be met. Therefore, in cases where the statutory objectives of NHS England might be
undermined, following the decision of a delegated committee, these concerns would have to be determined and amended retroactively.
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“Figure 12: Voting Process in a Joint Committee”, Operating Model: Co-commissioning of Primary Care v5, P.20
Croydon, Kingston, Merton, Richmond, Sutton, Wandsworth CCGs and NHS England
Appendix 2
Report to CCGs on an option to move towards delegated commissioning
Appendix 3
NHS England have produced a number of supporting documents in regards to Cocommissioning.
The following link provides details of the 2014/15 delegated proforma and associated
submission materials, including
1.
2.
3.
4.
Annex B, “Submission proforma for delegated commissioning arrangements”
Annex C, “Model wording for amendments to Clinical Commissioning”
Annex E “Draft delegation by NHS”
Annex F, “Delegated Commissioning model-draft terms of reference”, November
2014
http://www.england.nhs.uk/commissioning/pc-co-comms/
It is expected that NHS England will provided an update on 2015/16 requirements and
submission documents by July 2015.