Discussion roundup: Clinical commissioning groups

The debate explored whether GPs are able to balance their workloads with new managerial duties. Photograph: Martin Godwin for the Guardian

Mark Wilkinson, chief officer, NHS Barnsley CCG: "We have to look at how we can fully utilise the CSU. I'm challenging my team to explore CSU options rather than simply recreating our own in-house capacity."

Phil Mettam, chief officer, NHS Bassetlaw CCG: "We have developed a way of working where staff have supported autonomy, clinicians are predominantly involved in service conversations (not governance), and everyone is encouraged to be pragmatic and flexible."

Jonathan Sheffield, chief executive, the National Institute for Health Research Clinical Research Network: "In some parts of the country, barriers to research have really been broken down by the determination of CCG's to make sure excess treatment costs related to research are being covered. But in other areas, because the guidance has yet to be revised by the National Commissioning Board, there has been some rejection of requests for excess treatment costs. We also have some instances of new qualified providers being unsure, and even sometimes unwilling, to support research in their clinical area."

Mark Wilkinson: "I'm not sure the actual barriers have changed as a consequence of reconfiguration. What I suspect has happened, although this will be highly variable across the country, is that attention (at least in the transition from PCTs to CCGs) has been focused elsewhere on setup, building new relationships, bedding in new governance arrangements etc."

Chris Naylor, fellow, King's Fund: "I think there's a general spirit of wanting to support learning and sharing of best practice – the barrier, though, is time, which for most people working in CCGs over the last year has been in very short supply."

Jonathon Fagge, chief executive, NHS Norwich CCG: "Last year we commissioned Equal Lives to develop a co-production model for us. The first project will be community mental health services. Equal Lives will recruit and support a community involvement panel of service users and community representatives. We will jointly develop the service description, manage a wider public consultation, co-produce the service specification, and then involve the panel in bid evaluation."

Mark Wilkinson: "At Barnsley CCG we are determined to become an example for patient and public engagement. Quite how we move from aspiration to delivery requires quite a shift. And I do think this is an area where CCGs could do with some help."

Jonathan Sheffield: "The NIHR Mental Health Research Network team have strong links to patient groups and we involve patients in the design of questions to be answered through research, as well as specifically using patients to review protocols prior to implementation of studies."

Victoria Bleazard, associate director of policy, research and campaigns, Rethink Mental Illness: "We often hear of people being consulted by local authorities and different bits of the NHS at the same time on pretty much the same questions. Some models are being developed to try and join up engagement across agencies so that there are more resources to do it better and properly understand local need."

Phil Mettam: "We try and engage on a themed basis ... We hold an annual Big Health day where we invite people with a learning disability and their carers to tell us what they think about how the NHS, LA, and voluntary sector is supporting them and looking after them."

Robert McGough, partner in DAC Beachcroft's health commercial team: "There are a variety of approaches to member engagement as the governance structures have been set up in varying ways – some have more centralised structures with more control in the governing bodies, others delegate to localities to get local practice engagement."

Jonathon Fagge: "Provided CCGs focus on improvement rather than assurance I believe we can be a catalyst for improvement in the quality of primary care, and maintain good relationships with our members."

Chris Naylor: "One concern I've heard raised is about NHS England having limited capacity to perform performance management responsibilities. Some CCGs seem to be anxious that they will be sucked into that role in spite of their intentions to strike a supportive relationship with members."

Michael Scott, chair of the NHS Confederation's Community Health Services Forum: "Our early experience as a provider is that we find that there could be stronger links, ie what we are asked contractually to deliver by the CCG can be at odds with individual practice priorities and vice versa."

Chris Naylor: "The financial environment is obviously a big challenge. To that I'd add the challenge of engaging local GPs and demonstrating to them that CCGs can bring about improvements for GPs and their patients."

Robert McGough: "I would add the challenge of understanding their "inheritance" from the PCT – what the legacy contractual and structural issues are, what has actually transferred to the CCG, and what else may be delegated from NHS England, as well as how they engage with effective commissioning support services."

Richard Vautrey, deputy chair of the British Medical Association GP committee: "Many CCGs are still trying to get the right staff in place. All are faced with working out the right relationship between them and the new bodies working with them, particularly the area team of NHS England, local authorities and CSUs."

Jonathon Fagge: "Overall I feel very optimistic about how CCGs have coped with the challenges so far, and are geared for the future. The CCG leaders I meet are ambitious for their organisations, clinically engaged and patient-focused, and ambitious to create a legacy of genuine improvements in healthcare."

Jonathan Sheffield: "The introduction of CCG's offers a real opportunity for clinical involvement in the development and delivery of research. The opportunity to make ground breaking improvements in clinical healthcare is through research and any healthcare provider needs to have an approach to research that ensures that the best, most modern, treatments are made available to patients."

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How clinical commissioning groups are handling new responsibilities

CCGs are here to commission health services and work with patients and practices to ensure they understand local services and their quality. Photograph: Alamy

One hundred days have now passed since 1 April and the official birth of clinical commissioning groups (CCGs). As a GP and CCG chair it has been one of the most exciting, frustrating and meaningful periods of my career.

For most CCGs, delegated authority from primary care trust clusters, and therefore responsibility, had been in place for some time before April. However the process of authorisation and establishing organisations undoubtedly became a necessary distraction, with process and structure the focus.

Authorisation was essential to ensure we build robust, patient-focused organisations capable of fulfilling our statutory duties. CCGs were the only part of the new system to have been through this process, despite the number of new structures in the commissioning system. Since authorisation it has been good to get back to what we are here to do — commissioning health services and working with patients and practices to ensure we understand local services and their quality.

Bassetlaw CCG is a comparatively small CCG, with 12 practices and 112,000 patients in north Nottinghamshire. We have the same issues as many of our neighbours – high mortality and morbidity levels, areas of significant deprivation, obesity and substance misuse. We have a two-tier local authority system and we are members of Nottinghamshire health and wellbeing board. However, 90% of our patients use acute health services based in northern England – in South Yorkshire (including Bassetlaw hospital as part of Doncaster and Bassetlaw hospitals foundation trust).

Much of our time, therefore, is spent developing partnerships. Many of the commissioning organisations we work with are new, including NHS England, public health teams and the health and wellbeing board. Practices and providers are important as pre-existing parts of the system, and have been essential in understanding our local health services and outcomes. We have built transparent relationships with our providers, openly discussing services, capacity and performance. We meet neighbouring CCGs regularly to discuss commissioning on a regional level such as cardiology services and networks.

Quality assurance forms a significant part of our role. Performance indicators and targets are a key part of this, but we have also reviewed issues raised by member practices and patients. Service development has been one of our most important work streams. It is essential that we seek continuous improvement in services for patients, and not simply monitor what we already have. GPs work closely with managers to improve pathways and we have successfully commissioned new musculoskeletal, dermatology, cardiac rehabilitation and community paediatric pathways for local patients.

As a CCG we have a strong sense of responsibility for our local population. Patient engagement is central to this. We have well established practice patient groups and groups within the CCG, and this role is led by our new lay member who has worked hard to ensure we have a new, meaningful approach. We have developed a series of summits with patients, carers and providers including extremely successful dementia and learning disability events.

We have a number of commissioning priorities as a CCG. Some, such as developing integration of services and pathways, have been enhanced by the development of an integrated care board chaired by the local authority. Some have arisen due to performance issues, such as A&E performance. We have worked closely with practices, visit A&E weekly and have commissioned increased capacity within the department and acute medical services with significant results. Targets are now being met and we have services with better access to senior staff over seven days and diagnostics.

There are significant challenges. Being allowed access to patient information is essential if we are to improve outcomes and commission effectively. Running cost, set at £25 per patient, is a blunt tool that does not take into account organisational size and fixed costs, or local health needs. CCGs, particularly those such as Bassetlaw, who have natural communities but are relatively small, are extremely lean organisations where clinical and managerial time is limited and we have learned to work as an efficient, effective team. It is essential that this is valued when we have assurance meetings and that reporting upwards does not distract us from our role.

We operate as just one part of a complex commissioning system. We need to ensure we are active partners alongside public health, regulators and NHS England, and that our clinical involvement and patient engagement lead to better outcomes.

After 100 days I'm optimistic. Clinical commissioning is delivering. The NHS needs it to succeed.

Dr Steve Kell is chair of Bassetlaw CCG and co-chair of NHS Clinical Commissioners Leadership Group

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