Primary care co-commissioning

Introduction to
primary care cocommissioning
Welcome and introduction
• Welcome and thank you for coming today. We hope you will find
it a really useful day which will help you to implement cocommissioning arrangements locally.
• So why co-commissioning?
• CCGs have consistently indicated that they wish to assume
greater responsibility for the commissioning of primary care
• 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.
Intended benefits for local
The overall aim of co-commissioning is to develop better integrated
out-of-hospital services based around the diverse needs of local
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.
The future vision
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
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.
Next steps towards primary care cocommissioning document
This event builds upon the Next steps towards primary care cocommissioning 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).
Key policy issues
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;
involvement in
primary care
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.
Conflicts of interest management
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
Development support
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.
Purpose of the day
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
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.
Primary care
Legal plenary
Overview of legal framework
• Same overall framework applies to all three models of cocommissioning
• Focus on options 2 (joint commissioning) and 3 (delegated
• 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.
PMS commissioning – NHS England
• 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
• Procurement
National Health Service (Procurement, Patient Choice and Competition) (No. 2)
Regulations 2013
Monitor guidance
Future NHS England guidance
Joint commissioning
• Establishment of joint committee
• Governance
• Membership, including non voting attendees
• Ability to delegated CCG functions to joint committee (section
• Benefits of joint committee approach
• Integrated working
• Conflicts of interest
Delegated 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)
Primary care
Finance plenary
Introduction:- How did we get here?
• 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
…..and co-commissioning
• Allocative nightmare:- lets face it we struggle with
• Start point:- what is spent and where.
• Baseline return from Area Team for 2014/15:- a fixed
• Recurrent Allocation, not necessarily “available
The aim
• 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 Issues
• 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
What comes first the business rules
or the allocation?
Business Rules
• 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.
• 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.
Finance Element of Delegation
• 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!)
Primary care
Technical plenary
The Approvals Process
• 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
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
• 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
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 cocommissioning should be emailed to as well as to region
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
• 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 cocommissioning 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
Ongoing Assurance
• 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
• Delegated arrangements – noon on 9 January, with
both CCG and NHS England sections complete – to
• Joint committee proposals – 5pm on 30 January,
with both CCG and NHS England sections complete –
Co-commissioning webpage
Please visit the primary care co-commissioning webpage
on the NHS England website:
• 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
Primary care cocommissioning
Closing remarks