Commissioning the delivery of NHS services

The UK government’s Health and Social Care Act 2012 moved responsibility for commissioning care to clinicians, by creating clinical commissioning groups (CCGs). Clinical commissioning groups are new statutory NHS bodies making commissioning decisions and healthcare strategy for their community.
    
CCGs are different entities from previous NHS arrangements, with each GP (General Practitioner) practice being a member and clinicians leading commissioning decisions. The CCG is its member practices; the members are the authority and appoint governing body members.
    
In addition to their current clinical and business demands, GPs now have new powers, roles and responsibilities. With the transfer of responsibility for commissioning healthcare and services to CCGs, there will be an increase in the demands placed on GPs, and fellow clinicians, to perform these new statutory duties in a manner that is transparent. It is vital interested parties are able to hold them to account; most notably patients and the public. Good governance is an important aspect for delivering that transparency and accountability, but may not be well understood by those likely to be involved in running CCGs.

Supporting clinicians
The Institute of Chartered Secretaries and Administrators has produced a draft code of good governance, specifically created for clinical commissioning groups. The aim is to develop a concise document that outlines governance principles that will support clinicians, and those that work with them, to perform their new commissioning activities and help to maintain public trust in clinicians and the NHS. Feedback from healthcare experts will contribute towards the final version of the ICSA Code.
    
Good governance in NHS clinical commissioning groups plays an important role as one aspect of improving the quality of care commissioned. We have designed six principles to be universal and applicable to all CCGs in England, regardless of their size or collaborative arrangements and whatever the CCG has set out in its constitution.
    
Inevitably, the practice and procedures for each CCG will differ. The application of the principles, however, should be proportionate and appropriate for each CCG and its governing body, thereby reinforcing that good governance is an aide to clinicians in delivering the aims of the Act and improving the quality of care and health experiences of patients.

Using the principles
The high level principles provide CCGs and their governing body members with flexible guidance to be used in a manner that is appropriate to the needs of the organisation, and CCGs are encouraged to adopt an ‘apply or explain’ approach. CCGs will decide how best to implement each principle in order for it to be proportionate and effective, but should consider the best way to communicate to their stakeholders how they apply the principles.
    
It is hoped that all CCGs and their governing bodies will adopt the high level principles and include a statement in their annual reports as to how they apply the principles in order to deliver the group’s strategic aims for patients and the public.

Understanding each other's roles
The relationship between GP member practices, who make up the CCG, and the governing body is based on trust and a clear understanding of the position and responsibilities of each.

Individual GP member practices regularly contribute to, and develop, the CCG’s vision and work with the governing body to provide such support and guidance as detailed in the Act or in the CCG’s constitution.

The individual representative of GP member practices needs to have clear guidance as to their role and relationships within the CCG and the governing body. 


The various committees of the CCG and the governing body need to be open in their communications and dealings with the GP member practices, with dialogue based on the mutual understanding of agreed objectives.
    
GP member practices’ meetings need to be constructive and effective in demonstrating accountability to stakeholders.

Co-operation with all stakeholders
The NHS clinical commissioning group needs to cooperate with other clinical commissioning groups, NHS entities, service providers, local authorities and other relevant organisations with an interest in the local health economy.
    
It must ensure appropriate relationships and constructive dialogue at the right level with a range of identified current and future service providers, other CCGs and regulatory organisations, are in alignment with the agreed strategic aims.
    
It should maintain a schedule of the specific third party bodies, in relation to which the NHS clinical commissioning group has a duty to co-operate, and identify an individual CCG member, or authorised representative, to lead on those arrangements. Examples include: primary care services, specialised services and the work of the Health and Wellbeing Boards.
    
The CCG should regularly reviewing the effectiveness of these relationships and the processes supporting them, where necessary, taking proactive steps to improve them.
    
It should also develop, and regularly review, written agreements between appropriate partners, including other CCGs and locality boards (where they exist).

Working with external bodies
The CCG, and its governing body, should be clear about the form, level and scope, of cooperation required with relevant external bodies in order to discharge the CCG’s statutory duties:
    
The CCG governing body, and any committees should be aware of, and understand, the role of key bodies outlined in the legal and regulatory framework governing CCGs. Changes in the legal and regulatory environment should be discussed at the appropriate level and implemented accordingly.
    
Authorised individuals responsible for maintaining appropriate relations with each body should be identified. They should provide relevant information to each organisation in a manner that is timely, accurate and appropriate.

Understanding legal frameworks
Members of the governing body need to understand their role and responsibilities collectively and individually in relation to the legal and regulatory frameworks that apply to them.
    
They need to recognise and respect that all governing body members are equally responsible in law (notwithstanding the additional responsibilities of the Accountable Officer) for the decisions of the governing body, as detailed in a comprehensive induction and ongoing support.
    
They must ensure compliance with all relevant legislation and regulation applicable to the CCG, and the activities it undertakes, and make appropriate public statements to confirm that this is the case.
    
They must assure that all governing body members are properly appointed and are qualified to serve, supported by role descriptions and an agreed appointment process.
    
They must be alert to those matters reserved to the CCG and those delegated and reserved to the governing body, or other committee, including reviewing regularly the scheme of delegation, list of matters reserved, and the terms of reference for committees.

Compliance and good governance
The governing body needs to ensure that the CCG has made appropriate arrangements for compliance with such generally accepted principles of good governance that are relevant to it. This can include development of the CCG’s strategy, having taken into account the views, as far as appropriate and practicable, of stakeholders, as well as other functions which can be set out in CCG constitutions.

It needs to involve members of the public and patients in the work of the CCG, including the planning of commissioning arrangements, changes to those arrangements and the decision processes associated with any such arrangements.
    
It must ensure the governing body meetings are open to the public, unless not in the public interest, with clear criteria as to when matters of confidentiality or business sensitivity require private discussions.
    
The governing body must fully support the members of the governing body in fulfilling their roles, and it must have open and regular communication informing stakeholders about the work of the clinical commissioning group.

Open, robust and transparent
Governing body members must demonstrate probity and integrity in their governance role and when representing the clinical commissioning group. Governing body members must ensure the CCG adopts and adheres to open, robust and transparent processes.
    
Governing body members must act in the best interests of the CCG, its patients and the public, in accordance with CCG agreed policies, procedures and values.
    
They must adopt and adhere to a conflict of interest policy, which is publicly available. They must establish and regularly update the register of interests, which can be easily accessed by the public, as well as ensure conflicted governing body members are identified and do not participate in decision-making.

Further information
www.icsaglobal.com