Understanding how commissioners work, and the ways in which HITs can influence their decisions Louise Rickitt & Mel Green June 2015

Introduction – clinical commissioning groups Created by the 2012 Health Act, CCGs are membership organisations, led by clinicians and owned by local GP practices (25 in South Gloucestershire) CCGs are responsible for purchasing healthcare services, including emergency and urgent care, community health, maternity and children’s services, mental health and learning disabilities healthcare services (South Gloucestershire CCG’s total budget in 2015/16: £275.6m) NHS England is responsible for commissioning primary care services (GPs, health visitors, opticians, pharmacists and dentists), prison healthcare and specialist services Local Authorities are now responsible for commissioning all public health services, including alcohol and drug misuse, smoking cessation, obesity, immunisations), Healthy Child services including school nursing, health checks, sexual health, falls prevention June 2015South Gloucestershire Clinical Commissioning Group: - Leading you to Better Health2 How CCGs work All GP practices are legally required to be members of a CCG. Nearly one-third of the South Glos member practices are actively involved in the CCG leadership, with GPs taking responsibility for specific clinical leadership roles on the Board and as clinical leads for key commissioning areas. CCGs cover GP locum costs, enabling practices to release GP time for CCG work A CCG Board must have a majority of clinicians, including a secondary care clinician and a nurse director. South Glos CCG directly employs 42 members of staff to manage all aspects of the our commissioning duties and support the GP clinical leaders. It also has an SLA with the South-West Commissioning Support Unit to provide expertise in areas of contract management, IMT, performance and data management, and service development

Introduction - the commissioning landscape and how the NHS budget flows June 2015South Gloucestershire Clinical Commissioning Group: - Leading you to Better Health3

How CCGs work – the annual commissioning cycle June 2015South Gloucestershire Clinical Commissioning Group: - Leading you to Better Health4 April – June July - September October – December January - March April - June CCGs consider health needs assessments, national reviews, latest evidence, feedback from patients and GPs, performance and quality issues, progress towards delivering commitments/ existing strategies and work programmes CCG clinical and programme leads in working groups/ programme boards/ meetings with providers hold initial discussions about ideas for future service development. Focus shifts to development of business cases. Need to be evidence-based, setting out expected impact on CCG’s finances, quality, performance, and health outcomes. Plans reviewed/ revised following publication in December by NHS England of CCG budgets, business rules and detailed national guidance Business cases prioritised, discussed and agreed by CCG’s Clinical Operational Executive, with any significant investments ratified by the Board Many will then be taken forward as part of annual contract negotiations underway with existing providers Implementation phase

How CCGs work – often more complex in practice June 2015South Gloucestershire Clinical Commissioning Group: - Leading you to Better Health5 Some service developments are very complex and large, requiring years of work on developing the model of care, with involvement from providers, patients, clinicians and other stakeholders. Nevertheless, investment decisions and extent of roll out in the following year are often taken as part of the annual commissioning cycle. Example: the development and implementation of an new model of care for rehabilitation, reablement and recovery in South Gloucestershire, a large change programme involving multiple projects and work streams Work began in 2012, developing a model of care with Bristol & North Somerset CCGs, the South West Clinical Network and within South Gloucestershire, the Local Authority and a wide range of stakeholders, including patients and carers Phase 1 implementation. Work underway to move towards the new model of care using opportunities as they arise. Includes the award of a new Community Services contract to Sirona Care in April 2014 which enabled a range of service developments; ‘winter planning’ funding which has been used to commission a community service from nursing and residential homes within South Gloucestershire. Phase 2 implementation. The commissioning of long term arrangements for community rehabilitation services, including redeveloping the Thornbury and Frenchay hospital sites. The CCG agreed the outline business case and procurement approach in March 2015.

Opportunities for influencing CCGs’ decisions June 2015South Gloucestershire Clinical Commissioning Group: - Leading you to Better Health6 Understand a CCG’s priorities: all CCGs must agree and publish a Joint Strategic Needs Assessment (JSNA), a Joint Health and Wellbeing Strategy, a 5 year strategy, and an annual commissioning plan (usually referred to as an operational plan). If not an explicit priority, CCGs are also interested in ideas that help towards implementing national service transformation plans (eg NHS England’s Five Year Forward View). Understand the likely impact on CCG finances as well as health outcomes. Ideas that save money for CCGs – particularly in terms of spend on hospital services – as well as improve quality are likely to be welcomed with open arms (and at any time of the year). Get to know the CCG clinical leads. Approach them with service development ideas as early as possible in the financial year. Can these be linked to (or even better support) existing CCG work programmes? Any proposals that require investment in hospital services will need to be included in formal contract negotiations Be realistic: proposals that involve a significant investment by CCGs in hospital services are unlikely to be funded in the current climate. Strategic clinical networks can be another route into influencing CCG decision making