Developing the NHS Commissioning Board
Department of Health, 8 July 2011
The DH has provided more detail about how it proposes to structure the NHS Commissioning Board (NHSCB), with further stakeholder engagement planned for the near future. While Sir David Nicholson envisions the clinical commissioning groups (CCGs) as both the 'cornerstone' and the 'engine' of the new arrangements, he foresees the Board's role as putting 'the "N" in NHS.' Nicholson insists that there is 'important continuity with the current system' and that the reforms build upon 'the vision for systematically improving the quality of care' provided in the Darzi Report. Moreover he offers assurances that the central structure is there 'to support and hold local groups to account, not to domineer or micro-manage.'
Sections of the document are devoted to the Board's purpose, processes and people. The key points from each are discussed below:
- Alongside its commissioning responsibilities, the Board is expected to 'ensure that the whole of the architecture is cohesive, coordinated and efficient.'
- As part of the intended 'mature and respectful approach' the relationship between NHSCB and the CCGs, the former will deliver: a framework outlining resources and accountable outcomes for CCGs; adaptable commissioning tools; an ongoing support programme to help CCGs to identify strengths and shortcomings; a 'robust' process for authorisation; and a 'transparent and rules-based' system for intervention.
- The NHSCB will host both clinical networks (to 'advise on distinct areas of care') and clinical senates ('multi-disciplinary input to strategic clinical decision making').
- There will be a number of frameworks in place to support NHSCB with its 'overarching role' of driving up outcomes. Alongside the Outcomes Framework itself (which covers such areas as prevention, patient experience, long-term conditions and safety in 2011/12) are frameworks for accountability, choice and emergency planning.
- It is noted that both the Future Forum report and the Government's response underlined the NHSCB duty to promote the NHS Constitution. This will involve ensuring local commissioners implement national standards and that health inequalities are alleviated among other tasks.
- NHSCB should be 'a champion for patients and their interests', which will require not only consistent patient engagement but also 'access to high quality insight into what patients, carers and the public want and expect from NHS services.'
- Among the most significant of the NHSCB's other functions outlined in the document are to: account to parliament for progress on agreed outcomes; develop and oversee the CCG system; commission about £20bn of specialised and primary care services; promote innovative examples of integrated care; 'make choice a reality for patients'; and to devise a medium term NHS strategy with partner organisations.
- A number of preferred characteristics for the NHSCB culture are listed, including: focus on quality and outcomes; 'patients, clinicians and carers at the heart of decision-making; objective, evidence-based activities; a flexible approach including integration and cross-boundary working; partnership working; transparency; and accountability.
- Alongside its accountabilities to government and parliament for mandate delivery and attaining value for money, the Board should also account for its performance to patients and public through its annual report and other communications.
- The document also considers the effective partnerships that the NHSCB needs to develop including: patient groups (both HealthWatch and other appropriate bodies); the full range of healthcare professionals; healthcare providers (primary, secondary and social care, from all sectors); local government ('critical area' in light of new responsibilities for councils); industry (pharmaceutical and technology companies); and other national bodies (such as Monitor, CQC, Public Health England and NICE).
- It is asserted that, 'Although its purpose is simple, the functions and responsibilities of the Board are wide-ranging and complex.' Processes are categorised as either core (upholding and embedding values), business (effectiveness and efficiency) or oversight and support.
- There is a commitment to publish more information on the processes in the future, but the document provides some early thoughts about some areas, including:
o Quality - NHSCB 'must aim to secure continuous improvement in outcomes.' The standard contracts drawn up by the Board will offer incentives, but the Quality Standards will act as 'the backbone of the commissioning system.'
o Information - Real-time information is the preferred option wherever possible, with a common set of information utilised by both NHSCB and CCGs advocated to enhance efficiency.
o Authorisation of CCGs - the authorisation process will not be a one-stage process, 'rather as part of a broader developmental relationship' between CCGs and NHSCB. NHSCB is also expected to ensure that CCGs have sufficient support systems and 'robust arrangements for collaborative commissioning' in place.
- The NHSCB will have a chair and at least five non-executive members to hold executive members to account, ensure governance in line with the Nolan principles and play a part in relationship development. There should be less executive members than non-executives with the following roles envisaged: chief executive; nursing director; medical director; director of finance, performance and operations; and director of commissioning development.
- In an effort to alleviate any confusion about the NHSCB and its board, the former should be given an alternative name, e.g. NHS England.
- While around 8,000 staff are currently involved in work that will come under the auspices of NHSCB, it is thought this will be reduced to about 3,500. Around two-thirds will be part of the so-called 'field force' responsible for CCG relationships and direct commissioning.
- There is an acknowledgement that a 'relatively complex structure' will be necessary for NHSCB: national organisation around the five domains of the NHS Outcomes Framework, with national professional leads for each, supported by clinical advisory teams; supporting functions under national directors; and functions organised at regional level.
- There are a number of other areas identified for leadership capacity alongside the five outcomes domains including: arrangements for key services (including children's health, mental health, older people, maternity and primary care); advice and leadership for specific areas within domains (e.g. cancer, diabetes, HCAIs); advisory system for NHSCB (involving Royal Colleges and specialist societies); clinical networks 'as a transmission belt' for the Board's objectives to local professionals.
- The importance of patient, carer and public engagement is once again emphasised, entailing: PPE playing an integral role in culture and leadership; engagement model for NHSCB setting 'the tone for the commissioning system'; all NHSCB staff with core skills in engagement and involvement; and decisions clearly informed by 'patient insight and intelligence.'
- It is proposed that national level tasks fit within six areas: finance, performance and operations (financial strategy, CCG authorisation, tariff formulation); commissioning development (CCG support, national primary care contracts); patient and public engagement, insight and informatics (ensuring choice and patient involvement are enhanced, utilising informatics to increase service quality); improvement and transformation (NHSCB commissioning strategy, 'foster world-class capacity for change'); policy, corporate development and partnership (health policy and design, negotiating mandate with DH, relationship management); and chief of staff (human resources, talent management).
- Functions to be undertaken at a local level include: management of day-to-day relationships with CCGs (including provision of support and gathering best practice); the majority of NHSCB's direct commissioning responsibilities (including primary medical services, dentistry, pharmacy); the 'sub-national footprint for the Board's clinical functions'; and local stakeholder engagement.
- While the DH is not able to fully clarify the local organisational structures, they confirm that 'current PCT cluster arrangements will be reflected in the initial local arrangements' plus the creation of four 'commissioning sectors' in line with the four SHA clusters. It is envisioned the latter group could be responsible for: leadership of local teams; and hosting of a specialised commissioning team.
- It is argued 'there would be real value in aligning the functions' of other national organisations such as CQC, Public Health England and possibly Monitor to facilitate working across common regional areas.
- The need 'to adopt an innovative and consistent approach to interacting with staff' is recognised. It is proposed this will involve: induction covering core NHSCB objectives; recruitment to focus on 'behavioural strengths and attitudes' as well as skills and experience; staff assessment to incorporate contributions to driving up quality and outcomes; and a fluid organisational structure with staff urged to move between teams.
Further details on areas such as senior appointments, the proposed operating model and the NHSCB structure are all expected to be published in advance of the establishment of the Board in shadow form in October.