Wiltshire’s Clinical Commissioning Group is 100 days old – and into the hard work

Written by Tony Millett.

Last week the National Health Service celebrated its sixty-fifth birthday – a distinctly wobbly anniversary. This week Wiltshire’s GP-led Clinical Commissioning Group (CCG - which replaced the Primary Care Trust - PCT) is a hundred days young.

It is, of course, far too early to attempt a report on the CCG’s progress. As a commentator said recently, changing anything in the NHS is like turning round the proverbial super tanker.

However work is going ahead in Wiltshire CCG with some speed. One advance being rolled out across the county is a programme to speed up dementia diagnosis.  Improvements in the care of those with dementia is a much more complex and wide-reaching problem.

The CCG’s first major headache is the government’s new NHS 111 urgent care ‘phoneline.  The Wiltshire service is in the hands of the commercial company Harmoni under an inherited contract.

The service is still not considered safe enough to go live. In this Wiltshire CCG are not alone. A recent survey by the GPs’ journal PULSE of 440 GPs found that only eight per cent believe the computer based triage system at the call centres is safe for patients.

Coming soon will the expense and organisational risk of the tender process for Wiltshire’s community maternity services.
Looking ahead, the CCG have in the pipeline a new plan for community healthcare to bring services closer to patients:  “The agreed approach is to make all health related local services become based in practices with specialist services clearly supporting the practices.”

Already the CCG’s leaders are working with staff at Great Western Hospitals (who hold the contract for all Wiltshire’s community healthcare) to upgrade the neighbourhood nursing teams To maximise the teams’ impact they are employing care coordinators.

It is not yet clear how far the CCG’s plan will bring medical services into practices.  But at last month’s meeting of the CCG’s governing body, its Finance Director, Simon Truelove, gave a warning that “By taking out small elements” from the work the major hospitals do now, there is a “risk of destabilising our acute hospitals”: “We have to be careful about taking out low level services.”

One achievement the CCG has logged is that all their contracts with service providers for the current year have already been signed.  Not something achieved by this stage of the financial year under the PCT – although the PCT had more and wider commissioning responsibilities.

It is very difficult to judge how far the government’s promise in 2010 to reduce NHS bureaucracy and its costs have been achieved with the introduction of the CCGs.  We know that Wiltshire CCG’s running costs are currently about one third higher than were the PCT’s.

Staffing levels are impossible to compare accurately due to the CCG’s reduced amount of commissioning and their outsourcing of various ‘back office’ elements – including HR and finances – to an independent Commissioning Support Unit. And they have no buildings to maintain.

In June 2011 the PCT employed 240 commissioning staff.  By 31 August 2012 this headcount had fallen to 203.  The CCG employs (as at May 31 this year) 95 people.  But some of those are part time and that total equates to 83.81 whole time equivalent staff.  They are still recruiting.

On top of those staff numbers and costs are the GPs who have to be replaced at their practices when they attend CCG meetings and events.

Under his recent Spending Review for 2015 George Osborne intends to take £3.8 billion from the NHS budget to hand to local authorities to deal with rising social care needs – and costs.  He also plans to cut NHS administration costs by about another tenth.

This has already roused one Midlands CCG chairman to worry in a blog about “Running Costs”:

“The £25 [per head] running cost is already a blunt tool, not taking into account size of organisation or local health needs. The commissioning system has already lost a significant number of experienced staff and is more fragmented.”

“CCGs are already incredibly lean…There’s a point where a lean organisation becomes an ineffective one.”

Some of England’s 211 CCGs have been quick to arrest the decline in investment in primary care by significantly boosting budgets for enhanced local services.

The ‘locality’ or sub-division of Wiltshire CCG which includes the Marlborough area is NEW – for North and East Wiltshire. NEW has announced details of their 2013-2014 budget for these enhancements.

Their aims are quite clear:
“Reduction in urgent admissions to acute hospitals from care homes – reduction in urgent admissions through appropriate primary care interventions – increased delivery of local services i.e. patients managed by GP or outpatient services provided in the primary care environment.”

In addition the agreement will help achieve the NHS savings target – known by the acronym QIPP (a very serious level of savings unfortunately pronounced ‘quip’.)

The money to be divided among NEW’s nineteen practices (with 165,338 patients) through this agreement is £1,192,087.  Of this nearly a fifth (or £248,006) is described as the ’Basic Commissioning Element’.

It covers some of the locality’s organisational costs:
“Each practice to have a named Commissioning lead GP – GP attendance at 70 per cent of regular locality meetings… – Carrying out 100 per cent of audits as agreed at locality meetings… – Create a register of between 0.5 and 1.0 per cent of patients in each practice most at risk of hospital admission…– A representative from each practice to attend their appropriate local area board meeting (or health equivalent) annually – Attend regular GP clinical forums.”

This money, like the rest of this local budget, will be paid quarterly “on the production and review of the appropriate evidence” to satisfy the CCG’s executive that the tasks have been completed. Quite an administrative job in itself.

During the on-off progress of the government’s Health and Social Care Bill, it was claimed locally that savings made by the future CCG on the £25 per head running costs budget would go towards front line services. It is now clear that, over and above the £25 per head set by the government, some of what are essentially  running costs for the ‘locality’ are shown as coming  from ‘front line’ budgets.