The new NHS Commissioning Landscape 8 October 2012 Nigel Littlewood Head of Commissioning Development, NHS London

1. NHS Commissioning Board 2. Clinical Commissioning Groups 3. Commissioning Support Units 4. Similarities, differences, challenges and opportunities 5. Discussion

NHS Commissioning Board

Providers Funding Accountability Other Parliament Patients and Public Local HealthWatch contract Health & Wellbeing Boards (HWBs ) Public Health England Clinical Commissioning Groups (CCGs) contract Monitor contract Local Authorities (incl. Public Health) Commissioning Support Services NHS Trust Development Authority NHS Trusts Joint licensing between Monitor and CQC CQC National Regional ‘Footprint’ / Local Health Education England DH (SoS) NHS CB (London) Clinical Networks NHS TDA (London) FTs London LETBs Work together to ensure commissioner support for aspirant FTs Clinical Senates Following Royal Assent of the Health and Social Care Bill, the NHS landscape will look very different from April 2013 Public Health (London) HealthWatch England Independen t Sector Accountability for results Primary Care contractors contract Commissioning Assembly London Clinical Commissioning Council NHS Property Services NHS Prop Services (London ) Information Centre

NHS Commissioning Board was established as an ENDPB on 1 October 2012 Chief Executive David Nicholson Chief Operating Officer Ian Dalton Chief of Staff Jo-Anne Wass Director Commissioning Development Barbara Hakin Patient Engagement, Insight & Informatics Tim Kelsey Director Policy, Corporate Development and Partnership Bill McCarthy Director Improvement and Transformation Jim Easton Finance Paul Baumann Medical Director Bruce Keogh Nursing Director Jane Cummings Chair Malcolm Grant Non-executive directors Ed Smith Ciaran Devane Margaret Casely- Hayford Dame Moira Gibb Mr Naguib Kheraj Lord Victor Adebowale

The NHS Commissioning Board has a number of main functions Oversight and leadership of the new commissioning system including assuring and supporting CCGs to develop Oversee commissioning budgets including financial control and VFM Direct commissioning of around £20bn/£80bn of services, including specialised services, primary care, military health, offender health, and some services on behalf of Public Health England such as screening and immunisations Agree and deliver improved outcomes and account to Parliament Support quality improvement ensuring consistency of standards Develop commissioning guidance, standard contracts, pricing mechanisms and information standards Increasing choice for patients and championing their interests Ensuring plans for emergency resilience There will be four regional offices of the NHS Commissioning Board, each led by a regional director and reporting to the Chief Operating Officer. Within each region there will be local area teams roughly reflecting current PCT clusters

 Co-ordination and oversight of local area teams  Management of delivery of specialised commissioning  Support and co-ordination of clinical senates and networks  Performance oversight, including intervention and failure regime  Involvement in large scale reconfigurations  Co-ordination and oversight of emergency preparedness  Stakeholder engagement, particularly with sub national presence of bodies such as CQC and Monitor  Information functions  Managing the Board’s day-to-day relations with CCGs, including providing development support, and monitoring performance and outcomes  Direct commissioning, covering offender health; military health, specialised commissioning; and primary care, including management of family health service functions  Professional and clinical leadership  Partner and stakeholder engagement, including representation on Health and Wellbeing Boards NHS CB regional offices – North, Midlands and East, South and London Local Area Teams of NHS CB reporting to each region. London has integrated region and LAT functions. Regional Directors have been appointed and are appointing to their structures  London - Dr Anne Rainsberry  Midlands & the East - Dr Paul Watson  South of England - Andrea Young  North of England - Richard Barker

The structure of the London regional team has been recently published Medical Director Director of Nursing Finance Director Director of Operations and Delivery Simon Weldon Director of Commissioning Business Office Regional Director Anne Rainsberry HR Director Director for Patients and Information Transformation Director

Clinical Commissioning Groups

CCGs are meant to be genuinely new organisations not simply a recreation of previous commissioning bodies 9 Secretary of State through Department Health PCT Board Responsible for delivering Functions, Duties and Powers Defines Functions, Duties and Powers Chief Executive & Executive Team Accountable for delivering Functions, Duties and Powers Chair and Non-execs Appoints Member practices GP Practice Governing Body Chair + Deputy AO CFO Any Others 2 ** Lay 2 x Clinician* NHS Commissioning Board Design & Agree Oversee and ensure enacted Appoint Accountable to Accou ntable on behalf of CCG NHS CCG Current lines of decision- making and accountability Future lines of decision- making and accountability *The two clinicians must be a secondary care doctor and a nurse (nurse cannot be a primary care nurse employed/with interests in a practice) ** There must be a minimum of two lay members. One lay member will cover Patient and Public Involvement, the other will cover financial management and audit

Camden Hillingdon Harrow Brent Ealing Hounslow Central London (Westminster) Barnet Enfield Haringey Islington Richmond Merton Croydon Wandsworth Kingston Bromley Bexley Greenwich South- wark Lambeth Newham Tower Hamlets City & Hackney Havering Redbridge Waltham Forest Sutton Ealing CCG has the largest population (c.390k) and number of GP practices (82). Central London (Westminster) CCG has the smallest population (c.130k) All are coterminous with their local authorities except for: City & Hackney CCG covers the boroughs of Hackney and the City of London. West London CCG covers the whole of Kensington & Chelsea and 12 practices in Westminster Wave 1 – 3 CCGs Wave 2 – 11 CCGs Wave 3 – 11 CCGs Wave 4 – 7 CCGs Barking & Dagenham Hammersmith & Fulham West London (K&C, QPP) Lewisham Camden There are 32 proposed CCGs in London Kingston and Richmond share a CFO Kingston shares their AO with the Local Authority Inner NWL CCGs are sharing one AO and CFO Outer NWL CCGs are sharing one AO and CFO All CCGs in NCL are having their own AOs and CFOs 2 NEL CCGs with their own AOs, but sharing 1 CFOs 3 NEL CCGs sharing one AO and CFO All CCGs across the South, except Richmond and Kingston currently want their own AO and CFO

The authorisation process is underway now 212 CCGs nationally are being assessed in 4 waves against 6 domains and 119 criteria The 6 domains are: –A strong clinical and professional focus – Meaningful engagement with patients, carers and their communities –Clear and credible plans which continue to deliver the QIPP challenge –Proper constitutional and governance arrangements –Collaborative arrangements for commissioning with partners –Great leaders who individually and collectively can make a real difference. There are 3 outcomes of the process: –Fully authorised with no conditions –Partially authorised with conditions –Established but not authorised The NHS CB will be working with CCGs to support them to meet any conditions ahead of April 2013

Evidence will be assessed against both the legal criteria of the Act, and the 6 domains Conditions Panel Authorisation Final Decision Board / Delegated Committee of NHSCB

Commissioning Support Units

CCGs have £25 per head running costs to pay for their internal costs as well as a range of commissioning support services 14 CategoryFunction / Service Health Needs Assessment Health needs assessment and forecasting (e.g. JSNA/HNA) Provider Management Clinical governance and quality support (e.g. SUIs) Contract monitoring, quality and performance management Safeguarding Individual Funding Requests and complex case management Procurement and Market Management Provider market assessment and development Contract definition and negotiation Procurement services Support for joint commissioning Medicines management and prescribing services Continuing care and funded nursing care Business Intelligence Data capture, management and integration ­ as per “the national at scale definition” Performance and activity reporting. Advanced and specialist analytic services Support for commissioning strategy and service redesign Commissioning intentions planning and support (e.g. CSPs) Health care efficiencies planning (e.g. QIPP) Support for clinical service change / pathway redesign Planning, management and implementation of service redesign Communications and PPE Patient Involvement Strategic Communications Patient Experience Business and Corporate Support (including back office functions) Financial planning, budgeting and analysis. Financial reporting and accounting Payroll and staff administration. Data infrastructure services HR support Legal advice Governance (corporate and information)

Three CSUs are taking shape in London, developing cost effective services that meet the needs of their CCG customers 15 North West London South London North Central and East London

Similarities, Differences, Challenges and Opportunities

There are a number of similarities with the current system A continuation of the basic arrangements : -Purchaser provider split more pure -Local, regional and national levels -Local strategic partnerships National planning requirements A continuing focus on financial challenges (QIPP) and meeting growing health needs PBR Tariff system continues, although this needs promote integrated whole system care pathways Development of the market and AQP continues as a commissioning tool Further focus on integrated care, population health, prevention, early intervention, long term conditions management The need to manage demand and developing care closer to home Ongoing patient choice agenda and strengthening of patient voice, including Healthwatch

There are a number of differences to the current arrangements in terms of commissioning 32 CCGs in London will be statutory, practice based member organisations The Mandate and Commissioning Outcomes Framework will drive improvement The Quality Premium will provide an incentive Commissioning Support Services set up, with CCGs having choice Local authorities will commission most public health services Health and Well Being boards will be driving local strategies There will be no statutory organisation at regional level NHS CB also will be a significant commissioner of services and may be the majority commissioner for some London hospitals Contracts for specialised services for London providers will be managed by the NHS CB London team on behalf of the country Clinical senates and clinical networks will be formal parts of the system A number of commissioners will commission services along patient pathways NTDA will manage non FT trust performance, working with commissioners

There are a number of challenges with the new commissioning arrangements Transition of London staff from 9 organisations to 75 Not losing the opportunity to deliver transformation Giving CCGs space whilst needing grip in the system For CCGs, keeping their membership on board and engaged NHS CB commissioning for established but not authorised CCGs CSUs supporting CCGs rather than leading Ensuring that commissioners collaborate across the pathway Driving integration of services and integrating commissioning as appropriate Health and Well Being boards ensuring implementation as well as local strategic improvement Tackling large scale change when pan London health leadership in the system is not clear

The new commissioning arrangements should deliver a number of benefits Greater clinical input into decision making More buy in from GP members of CCGs and a focus on population health as well as individuals Public health largely commissioned by local government Health and Well Being Boards providing a local population focus and joint decision making Much more freedom locally for CCGs and Health and Well Being Boards to set priorities and to innovate Commissioning support services operating at scale, customer and business focussed The need for close collaboration between commissioners Greater consistency of specifications and standards Greater efficiency with the NHS CB’s single operating model

Discussion