1. Primary Care Co-Commissioning Proposal to Members to move towards the CCG taking delegation of GP contract management Presentation to Members October 2016

2. Current Arrangements
CRCCG has maintained Level 1 – Greater Involvement since the Member vote in December 2014
NHS E retain all responsibilities concerning the commissioning and the management of GP Primary Care for CRCCG practices
CCG has lower levels of influence in relation to the way in which services are commissioned and / or which services are commissioned from Primary Care

3. National / Local Context:
Currently 55% of CCGs in England have taken on Level 2 (Joint) or Level 3 (Full) delegated responsibility for commissioning GP Primary Care services (114 out of 209), 2016/2017).
Within the West Midlands area, CRCCG remain the only CCG currently operating at Level 1 – Greater Involvement
Local CCGs are already operating under either Level 2 (WNCCG) or Level 3 (SWCCG) with WNCCG now looking to move to Level 3 with Membership support

4. Drivers for Change:
Hear multiple complaints regarding the lack of responsiveness of GP contract management currently
CCG understands that the status quo is not acceptable and changes must be made
The CCG has most resources in place to manage this, as the locality team has proven their effectiveness in responding to practice issues as they are raised
Evident that delegated authority to manage the GP contract on behalf of NHSE (level 3), will allow the locality team to be more effective in improving responsiveness of Primary Care Commissioning going forward
Jointly Commissioning (level 2) arrangements will not facilitate the fastest improvement

5. For Members Consideration
There are 2 options available to the CCG under Primary Care Co-commissioning:
Level 2 – Joint Commissioning
Level 3 – Full Delegation
Joint Commissioning arrangements will allow more influence on the services commissioned and the way that Primary Care commissioning is managed than under Greater Involvement
Experience of CCGs elsewhere has shown us that this hasn’t brought the benefits anticipated and so it is understood this level is unlikely to change the current situation significantly enough
Under Joint arrangements NHS E retain the decision making regarding Primary Care and have over-riding voting rights at the Joint Commissioning Committee
Full Delegation enables the CCG to make decisions on the way in which GP Primary Care services and the correlating budget are managed
Experience of CCGs across the West Midlands has shown that level 3 allows for effective locally focused Primary Care Commissioning

6. What this could mean for Members Level 2
named locally based contacts already familiar to you / your practice team (Localities Team to be renamed Primary Care Development team (tbc)) that know and understand local services, relationships and individual practice nuances
there will more influence working with NHS E about the services that are commissioned from Primary Care in the future
support for practices generally and where there are concerns to achieve contractual service delivery e.g. jointly agreed action planning with proactive support from the CCG Primary Care Development team
local knowledge and expertise on hand to inform NHS E when considering:
practice applications for merging contracts, partnership changes, DES management and procurement of any new local Primary Care contracts

7. What could this mean for Members Level 3
named locally based contacts already familiar to you / your practice team that understand local services, relationships and individual practice nuances
a single point of access for all GMS/PMS/APMS Primary Care commissioning / contractual issues
more flexibility and control about the services that are commissioned locally from Primary Care in the future e.g. the potential opportunity to develop a localised QOF
support for practices generally and where there are concerns to achieve contractual service delivery e.g. jointly agreed action planning with proactive support from the CCG Primary Care Development team
the team are much more likely to be able respond more quickly to concerns and queries raised by practices / LMC
local knowledge and expertise on hand when considering:
practice applications for merging contracts, partnership changes, DES management and procurement of any new local Primary Care contracts

8. Responsibilities and Functions that will transfer to the CCG if NHS E delegate managing the GP contract – Level 3:
Needs assessments to inform primary care planning and future commissioning of primary care to meet local needs
Design and implementation of locally commissioned services
General Practice budget management
Procurement of new Primary Care Contracts
GP contract and performance management: reviews, support improvement / development requirements
Approval of practice mergers, closures and new practices
Premises cost directives

9. Responsibilities and Functions that will be retained by NHS England:
Commissioning of Dental, Opthalmic and Pharmacy Primary Care services
Management of the national performers list, revalidation and appraisal and performance management of individual GPs
Capital expenditure functions
Section 7a functions e.g. national screening and immunisation programmes
Complaints management
NHS England continue to legally hold GP Primary Care contracts, however, delegate specified functions relating to performance and execution of contracts

10. Potential Benefits of moving to Level 3 – Full Delegation
Local focus and flexibility
Local solutions to meet the needs of the population in context
Local knowledge, experience and influence
Control over budget allowing greater flexibility to shift investment from acute to primary care in line with the STP work-streams
Commissioning of services across the whole patient pathway enabling greater integration of services
Opportunity to design more responsive locally commissioned services in a primary care setting
Greater opportunity for peer review to maximise engagement and collaborative effort to achieve continuous improvement and address variation across the patch

11. Considerations and Risks of moving to Level 3
Governance – perceived and actual potential for conflicts of interest; new Conflicts of Interest guidance and requirements to be implemented
Financial – delegated budgets adequate to cover increased functions and responsibilities
Assurance – additional CCG assurance reporting requirements to NHS England on a bi-annual basis presently
Transition – managing the transfer of responsibilities and functions to the CCG; this will require management resources internally, sufficient capacity is required
Constitution – changes will be required to reflect additional scope of responsibilities and functions

12. Resource, capacity and capability considerations:
The existing staff of the Localities Team will evolve further to ensure sufficient capacity and expertise to take on a comprehensive Primary Care Development role and will lead on delivery of the responsibilities as set out under Level 3 – Full Delegation which are not required of the NHS E Primary Care Hub.

13. Constitution considerations:
The existing CRCCG Constitution will need to be amended to reflect any proposed move from the current position under co-commissioning.
Members need to consider the following:
In order to facilitate joint commissioning the wording in the CCG Constitution would need to be strengthened to provide greater clarity in respect of:
Joint commissioning arrangements with other CCGs
Joint commissioning arrangements with NHS E for the exercise of CCG functions
Joint commissioning arrangements with NHS E for the exercise of NHS England’s functions

14. For Members Consideration:
Options
Stay as we are, NHS E manage the GP contracts
apply to NHS E to move to Level 2 – Co-commissioning with NHS E
apply to NHS E to move to Level 3 – Full Delegation and take responsibility locally with the existing Primary Care Team for the commissioning and management of GP Primary Care services and contracts from 1st April 2017.
Members are now asked to consider the following and to vote on:
whether they support the CCG moving from Level 1 – Greater Involvement
if so, do Members support a move to:
Level 2 – Joint Commissioning Or
Level 3 – Full delegation

15. CCG Internal Considerations:
Work with colleagues both internal and key stakeholders including Members, LMCs and others as appropriate to understand the appetite to move to Level 2 or 3
Ensure constructive and transparent dialogue on a regular basis to maintain relationships and to provide assurance on the process
Understand the aspirations relating to commissioning of GP Primary Care services
Contracting and Transactional responsibilities and the capacity and capability to take this work forwards
Collaborative working arrangements and opportunities with Warwickshire North CCG

16. Time Lines
September / October – Consultation with Members including circulation of information to support the voting decision via the established locality groups, lunch time meetings and AGM
17th October to 31st October – e-voting open for Membership vote seeking support under the new voting arrangements - Please note this is a practice vote to be submitted by the named clinical lead and is based on the new voting arrangements set out in the CCG Constitution. Details of how to vote and the number of votes for each Member Practice will be made clear in the which will contain the voting link.
4th November – Vote outcome confirmed to key Stakeholders and draft application to reflect this
If there is Membership support as a result of the vote of 67% which is required as set out within the amended Constitution:
7th November to 25th November – CCG Primary Care Lead to meet with NHS England to agree the application and establish whether this will be supported
5th December – application to be submitted by the CCG to undertake Level 2 or 3 as determined by the Membership from 1st April under

17. Questions???

18. Summary of Co-commissioning functions under Levels 1 -3
Primary care function
Greater involvement
Joint commissioning
Delegated Commissioning
General practice commissioning
Potential for involvement in discussions but no decision making role
Jointly with area teams
Yes
Pharmacy, eye health and dental commissioning
Design and implementation of local incentives schemes No
Subject to joint agreement with the area team
General practice budget management
Complaints management
Contractual GP practice performance management
Opportunity for involvement in performance management discussions
Medical performers’ list, appraisal, revalidation