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

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

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

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

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

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

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

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

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

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

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

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.

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

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

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

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 email 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

Questions???

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