A CCG Accountable
Officer has a range of statutory duties, which - if he/she fails to
perform - can lead to loss of office and potentially prosecution. Of
this long and intimidating list, there are two that are key - which the
NHS system rightly expects to be consistently and competently performed:
1. Make sure that the services you commission are high quality and safe.
2. Don't overspend your budget.
WEDNESDAY: QUALITY & SAFETY
The NHS England
Area Team chair a monthly quality surveillance group (QSG), which feeds
into a Midlands and East Regional group every quarter. I attend
personally whenever I can - it has the potential to add great value to
the mission to improve patient safety across local systems. It brings
together CCGs, NHSE, CQC, Monitor, TDA, Healthwatch, County Councils,
and the Deanery to share information about the provision of care, and -
where patterns emerge - consider how best to respond to concerns. Its
work is vital to manage the very complex regulatory environment, and -
if properly developed - could go a long way to ensure that those recent
high profile failures in NHS care are not repeated.
I am very much in
the reform camp of the QSG - it needs to develop as a system, and to
develop its ambition further. I used the publication of the Berwick
Report to set out my thoughts at the meeting this week.
1. It needs to have
an explicit and clearly stated purpose - more than any other body of
which I am a member, these groups can deliver and should adopt the
Berwick Challenge.
'The goal is the continual reduction in harm'
2. It must be more
transparent. The QSGs are currently FOI exempt, private, and
confidential. I know the reasons for this will have been advanced in
good faith (people must be able to speak candidly without fear of
sensational coverage or complaints of libel), but in the context of the
Berwick Report it seems outdated and ill-judged. It engenders fear by
excluding providers from the discussion or the outputs, removes
accountability from those raising concerns, damages our credibility when
we ask providers to be completely open with us, and limits our ability
to engage with providers about early indications of problems.
'transparency is essential - expect and insist on it at all levels'
3. It must empower
itself to act. We need a range of measured and proportionate responses
to safety concerns, where it escalates beyond the powers of the
individual commissioning CCG. Berwick is right that responsibilities for
these safety and improvement functions need to be more clearly vested,
but we have all the players round the table, and the opportunity to act
collectively and with impact.
'All NHS Leaders should place patient safety at the top of their priorities'
The discussion was
productive and real progress was made - both in terms of proposals for
informing each provider of any discussions or concerns raised, and for
providing local supportive intervention before we trigger a Risk Summit
from the Region. I hope we are able to implement these for the next
meeting, and use them as a starting point to drive forward the patient
safety agenda.
FRIDAY: MONEY
The advantages of
having a Finance Director with 'system memory' (knowledge of the how the
Norfolk PCT managed its books) coupled with real technical competence
(detailed understanding of the intricacies of hospital tariffs and
contract finance schedules) cannot be overestimated. As we prepare for
the next meeting of our Governing Body I am struck by how little time we
have had to spend discussing finance, and how much it has enabled us to
focus on the interests of patients, the care they receive, and our work
to improve the health of the population. To steal a line from McCoy to
Spock (and thus reveal myself as an occasional trekker) I have come to
trust her guesses more than most people's facts.
She has been away
from the office for a few weeks - conducting a detailed exercise on
budget adequacy - and we met to discuss the results and her forecasts
for the rest of the financial year. I tried to stay with her as we sank
into the detail, but the complexity is all but overwhelming. More on
this in a moment, but first a little context...
The NHS reforms
have generated huge amounts of work for finance teams, particularly
where CCGs have different geographies than their predecessor PCTs. In
Norfolk the ledger had to split vertically to four CCGs, and every
budget line potentially required different methodologies - some
generated by actual patient activity, some by weighted population, some
by geographical responsibilities, and some by service usage. This is in
addition to the horizontal splits that all systems have to complete, to
separate the PCT ledger into CCG responsibilities, Public Health,
Primary Care, and Specialised Commissioning. And all must be done in an
environment where money is tight, everyone has some degree of efficiency
challenge, and no part of the system can afford to be out of pocket on
the splits. What surprises me is not that our budget is wrong, but that
it is not far from being right. (I will leave funding formulas for
another time...)
Regular readers of
the HSJ and other journals will be aware of two current financial
headaches for CCGs - legacy debt and the size of the specialised
deduction. The legacy debt derives from legal restitution claims -
patients who believe they were wrongly denied Continuing Healthcare
Funding during a ten year period up to 2008. If the PCT couldn't fully
assess the size of these liabilities it
could not make provision for them in its accounts and these debts fall
on CCGs. Cases are still being processed (at CCG expense) and we expect
the final bill for Norwich to be in the region of £3 million.
The specialised
deduction is more complex. PCTs commissioned some specialised services
which are now commissioned by NHS England. CCGs no longer get the bills
for these services, and so the corresponding budget has been deducted
and transferred to NHS England. It was a very difficult set of
calculations without a great deal of time to put into effect, and it is
of little surprise that it is not completely right. We think we have
been overcharged by approximately 6.5million - approximately 3% of our
budget. NHS England are aware and are conducting their
own analysis. I am optimistic that we will get most if not all of this
returned, but at the same time we have to make plans to cover this
potential shortfall. Although there are going to be difficult
conversations behind closed doors there are no villains here - just a
lot of people trying to cope with a great deal of complex system change
while making sure the right amount of budget ends up in each part of the
system.
So Norwich CCG has a
potential shortfall (in addition to our 6.5million QIPP plan for this
year) of £9.5 million from a budget of 215 million - a little under 5%.
Savings of this scale were routine during my time in the private sector,
but create a real headache for NHS Commissioners. Simply put, none of
the options available to me in previous roles offer much of a solution:
1. I can't change input prices because most are set nationally through the National Tariff
2. I can't generate cost efficiencies in service delivery because I'm the purchaser rather than the producer.
3. I can't cut
overheads to a meaningful degree because commissioning is not a
particularly expensive activity - the total spend on Governing Body,
Management, Staff, premises, auditors etc. is just over 2% of the
budget.
4. I can't reduce
programme expenditure - even if I wanted to, I can't stop people
visiting their GP, hospital, mental health Trust etc. (and I don't want
to - I have no interest in leading an organisation that denies care to
those that need it)
The answer is of
course to modernise, to transform, to change the pathways of care so
that patients get the care they need first time, and in an efficient
coordinated way. My team and Governing Body clinicians have no shortage
of ideas. The constraining factor is that transformation costs money,
and the clinical and financial benefits rarely accrue in the same year
as the money was spent. The NHS know this and sensibly ring-fenced 2% of
the budget to fund transformation activities. But of course this
transformation fund becomes a contingency fund when holes begin to
appear in the budget. The majority of this year's transformation fund
(£3million of it) has been held back to cover the CHC restitution
claims.
CCGs have a real
appetite for improving local health services, and for investing for the
long term to improve health and wellbeing. We will find ways of doing
this while balancing the books. But the next time you read a commentator
call for scale and pace it is worth reflecting that the financial
reality is that unless there is a good evidence base, we must test
innovation smaller and slower than we would wish.
I have been invited
to speak at the Commissioning Summit next week in Nottingham - a panel
discussion on the £20billion challenge facing the NHS. The numbers are
bigger but the principles will be the same - I will share our solutions
on Thursday, and hope to bring back with me the solutions of others.
