CCG authorisation: Key facts

Introduction

Clinical commissioning group authorisation: Guide for applicants was originally published by the NHS Commissioning Board Authority in April 2012 and updated by the NHS Commissioning Board in October 2012.

The guide is designed to enable over 200 aspiring CCGs to determine the timing of their application for authorisation and to prepare that application. It is intended to help CCGs develop clear plans to progress through the authorisation process and become an authorised CCG.

Approach

CCGs are new, clinically-led organisations coming into being for the first time, and wishing to be as good as they possibly can be. Therefore the NHS Commissioning Board (NHS CB) will have an important responsibility to support the development of CCGs as they move through authorisation. The full potential of the clinical leadership of commissioning will emerge over time through learning, innovation and experience.

For this reason, the thresholds for authorisation reflect the current stage of CCG development, and are set in the context of a longer-term vision, where CCGs are supported to develop as they mature as organisations post-authorisation. Therefore the authorisation process should not be seen as an end in itself, but as a first step on a journey towards continual improvement.

Alongside the responsibility to provide support, the NHS CB will also have a parallel duty to assure that CCGs are able to commission safely, use the their budgets responsibly, and exercise their functions to improve quality, reduce inequality and deliver improved outcomes within the available resources. This assurance will also be sought through the process of CCG authorisation.

Principles

The authorisation guidance is based on the principles developed with emerging CCGs and patient and professional organisations that were set out in Developing Clinical Commissioning Groups: Towards Authorisation, published in September 2011. Authorisation should:

  • be a process ‘fit for purpose’ – sufficiently robust to enable a thorough and cost effective assessment of the CCG’s capacity and capability to carry out its functions;
  • be a process viewed by both the NHS CB and emerging CCGs as developmental, adding value and helping to improve quality and overall patient experience and outcomes;
  • set the tone for the future positive relationship between CCGs and the NHS CB;
  • minimise administrative demands for both emerging CCGs and the review teams, whilst delivering a process which is both rigorous and efficient;
  • ask for evidence which is a by-product of core business, as far as is possible; and
  • recognise that this is a unique process, as ‘start-up’ bodies CCGs will be building a track record of performance. Authorisation will therefore focus on confidence of potential to deliver.

Development of the process

The process was developed by working with CCGs, national primary care organisations and other stakeholders. CCG leaders have also been extensively involved in developing the overall approach including via a national event in January 2012, a round table bringing together patient and CCG representatives, and eight regional events between February and April.

Domains

The authorisation process is built around six domains, agreed with emerging CCGs and patient and professional organisations. Assessing CCGs through these six domains provides assurance that CCGs can safely discharge their statutory responsibilities for commissioning healthcare services. They are also intended to encourage CCGs to be organisations that are clinically led and driven by clinical added value. The domains are:

  1. A strong clinical and multi-professional focus which brings real added value
  2. Meaningful engagement with patients, carers and their communities
  3. Clear and credible plans which continue to deliver the QIPP challenge within financial resources, in line with national requirements (including outcomes) and local joint health and wellbeing strategies
  4. Proper constitutional and governance arrangements, with the capacity and capability to deliver all their duties and responsibilities, including financial control, as well as effectively commission all the services for which they are responsible
  5. Collaborative arrangements for commissioning with other clinical commissioning groups, local authorities and the NHS Commissioning Board as well as the appropriate external commissioning support
  6. Great leaders who individually and collectively can make a real difference.

Within each domain, the guide gives criteria, the threshold for authorisation for those criteria, the evidence required and the sources for that evidence. The thresholds have been set to ensure CCGs can be innovative in delivering improved outcomes, while also remaining safe as statutory bodies responsible for commissioning health services.

Authorisation process

There are three distinct phases for the authorisation process:

  • Pre-application: Emerging CCGs prepare to take on their full commissioning responsibilities. These preparations begin with a self-assessment, progress to the assumption of delegated responsibility, and then CCGs work towards establishment and authorisation. As part of their preparation, emerging CCGs begin to assemble the evidence they are required to submit.
  • Application: Each aspiring CCG will need to submit an application form to the NHS CB (or NHS CBA if pre-October 2012) on or before their agreed application date. The application form will need to be signed by the Chair of the governing body and the Accountable Officer.
  • NHS CB assessment: Only the NHS CB can legally make a decision on authorisation, although it will take on board the assessment and views of SHA clusters, the NHS CBA and other parties. The formal assessment will be based on the evidence gained from several key components including:
    • 360° stakeholder survey;
    • desk-top reviews;
    • case studies; and
    • site visits.

Application timetable

CCGs will apply to be authorised in four separate waves. The wave will comprise: 35 proposed CCGs in wave one; 67 in wave two; 63 in wave three; and 47 in wave four.

360° stakeholder survey Application submitted to NHS CB(A) Authorisation decision returned to CCG
Wave 1 June 2012 2 July 2012 December 2012
Wave 2 July 2012 3 September 2012 January 2013
Wave 3 September 2012 1 October 2012 February 2013
Wave 4 October 2012 1 November 2012 March 2013

Proposed CCGs in each wave will continue to develop throughout the year as they take on increasing responsibilities. All CCGs will take on their new commissioning duties, if authorised, on 1 April 2013.

CCG development

The Board Authority continues to work with all proposed CCGs over the coming months, providing them with a comprehensive package of development and support to ensure they are in a strong position to take on their full responsibilities by April 2013. This includes:

  • The draft applicants’ guide
  • A full data profile for their area
  • Draft assessors’ guides
  • An authorisation portal website (Knowledge Management System)
  • The CCG learning and support web tool
  • The leadership development and assessment process
  • Information pack to support self-certification
  • Financial governance framework

Governance and decision-making

The over-riding aim at each stage of the decision-making process will be to ensure that as many CCGs as possible are authorised and given the support they need to set themselves up as autonomous statutory organisations by April 2013.

The key aspects of the authorisation governance process are:

  1. Final evidence review stage

Once a CCG has submitted its “considered response” to the site visit report via KMS, a final evidence review will occur. Each CCG’s Key Assessor, Panel Chair and relevant Local Area Team (LAT) Director will finalise their recommendations to the moderation panel based on the site visit report plus the considered response that each CCG has provided. Together this will be compiled into a final evidence report that will be sent directly to the moderation panel for their consideration. The final evidence report will clearly highlight any criteria that still remain red following a CCG’s site visit as well as information on how many red criteria became green as a result of your site visit. Any difference of opinion between the assessors and a CCG over recommended outcomes will be clearly noted.

The principal difference between a CCG’s site visit report and its final evidence report is that the latter includes each CCG’s “considered response” within it. As such, a CCG will not have sight of the final evidence report before it is submitted to the moderation panel.

  1. The moderation panel

The moderation panel chaired by Dame Barbara Hakin will review the un-moderated conclusions of the assessment team, any disagreements between assessors and applicants over individual outcomes, results of a number of tests to ensure that appropriate quality assurance is in place, and consider outliers where a given CCG’s results appear at odds with the national trend.

If the moderation panel feels fully satisfied that a CCG has fulfilled all 119 criteria, it will make a recommendation for authorisation directly to the NHS CB committee. If however the moderation panel feels that a CCG has not yet demonstrated compliance with all criteria, it will make a recommendation to the conditions panel for its consideration.

  1. The conditions panel

The conditions panel chaired by Ian Dalton will review CCGs only where they have not yet met all 119 criteria. As such, they will consider the recommendations put forward by the moderation panel and propose conditions associated with any criteria that remain red. Where a condition is recommended, an offer of support to remove this condition will also be identified. The conditions panel report will then be shared with the CCG.

  1. Removing the need for any proposed conditions

The NHS CB has now built in a period of time prior to the meeting of the Board’s authorisation committee. This enables CCGs to seek to remove the need for any proposed conditions that are of a largely ‘technical’ nature (e.g. updated documentation required) or where the passage of time since the site visit means that the criteria can now be met (such as in the case of recruitment processes that were still underway at the time of the site visit).

For the criteria where a CCG – in conjunction with the NHS CB – now feels it can fulfil the full requirements, it will now have 10 working days to comment and/or submit additional evidence via KMS. Although additional evidence will be able to be submitted at this stage, it is not envisaged that substantive additional evidence would be required in order to establish that a proposed condition is not required.

It is important to understand that this additional period of time is not intended to replace or replicate the review of conditions imposed that is planned for March 2013. The March review (and subsequent quarterly reviews) are the appropriate place for considering conditions that are interrelated, require triangulation of multiple evidence sources, or relate to systemic issues for a CCG.

  1. Review of any additional evidence

Any additional evidence submitted by a CCG at this stage will be reviewed by the relevant Regional Director of Operations and Delivery for consideration and sign-off. Where they consider that sufficient evidence has been provided to demonstrate that a criterion has now been fulfilled, they will make a recommendation that the need for a proposed condition be removed. Their recommendations will then be passed to the CCG authorisation committee to enable a final decision to be made on your authorisation application.

  1.   The Board’s authorisation sub-committee stage

The Board’s sub-committee will consider recommendations from the moderation panel and/or the conditions panel, and any comments made by the regional team. This sub-committee will make the final decision on a CCG’s application, will confirm any conditions to be applied and endorse the relevant support offers. The NHS CB will then write to the CCG confirming the Board sub-committee’s decision.

This diagram sets out the process from desk top summary report stage through until the final decision-making stage of authorisation:

Authorisation outcomes

There are three possible outcomes to the decision on authorisation for each applicant CCG: authorised; authorised with conditions; or established but not authorised (shadow CCG). These are described in more detail below. All CCGs will be invited to agree a development plan with the NHS CB which focuses on developing CCGs to maturity, beyond the thresholds set for authorisation.

  • Authorised: The CCG has demonstrated to the NHS CB that it satisfies all the requirements for authorisation. A list of the powers and duties that a fully authorised CCG will have from April 2013 are set out in The functions of CCGs. The CCG will be invited to agree a development plan consistent with the potential beyond authorisation set out in the guide for applicants.
  • Authorised with conditions: If the CCG has not fully satisfied the NHS CB that it meets all the thresholds for authorisation, the Board may give it conditional authorisation by setting conditions or directing the CCG as to how it carries out any of its functions. Conditions or directions will be specific to the particular criteria that have not been satisfied, and proportionate to the level of risk associated with the relevant function.
  • Established but not authorised: Legally these CCGs are established ‘with conditions’ but where the conditions are such that it cannot be described as authorised to take on its functions as a CCG. The NHS CB will make alternative arrangements for commissioning for that population until the shadow CCG is ready to move forward to authorisation.

FAQs on the decision-making process

Q: What is the difference between a ‘fact check response’ and a ‘considered response’?

A: A ‘fact check response’ is provided by the CCG in response to its desk top summary report. It is where a CCG can correct any factual misrepresentations (such as in relation to the details of your CCG’s make-up, member practices or commissioning support arrangements). It is not designed to take account of any substantive comments a CCG wishes to make regarding the conclusions drawn or any additional evidence a CCG wishes to submit. A fact check should be returned by the CCG within 2 working days of the desk top report being received.

A ‘considered response’ is provided by the CCG in response to its site visit report. It is where a CCG can challenge individual criteria outcomes from the site visit stage. It is not designed to take account of any significant additional evidence. It will however give the CCG an opportunity to indicate where it believes it can make rapid progress over the following 3-4 weeks, prior to the new opportunity to submit evidence before the NHS CB makes a final decision on your application. A considered response should be returned by the CCG within 3 working days of the site visit report being received.

Q: What is the difference between the ‘site visit report’ and the ‘final evidence report’?

A: The site visit report is produced by the Key Assessor and Panel Chair following a CCG’s site visit. Once a CCG has submitted its “considered response” to the site visit report, the Key Assessor and Panel Chair review this and include it in the “final evidence report.” It is the final evidence report that is submitted to the moderation panel for their consideration.

Q: Why won’t my CCG have sight of the ‘final evidence report’ before it is presented to the moderation panel?

A: CCGs will not see their final evidence reports before they are submitted to the moderation panel because they will already have had sight of their site visit report. As the only difference between the two reports is the input from the CCG itself, it is not necessary to share this with the CCG before the moderation panel stage.

Q: Will my CCG be able to see the final evidence report at any stage?

A: Yes, this will be sent to the CCG following the moderation panel stage, along with any recommendations the moderation panel intends to make to the conditions panel. Your CCG will then have an idea of any conditions that look likely to be recommended by the conditions panel.

Q: Why is my CCG’s final authorisation decision now later than originally announced?

A: In order to accommodate the additional time in which a CCG may seek to remove the need for proposed conditions, it has been necessary to push back the dates for the Board’s authorisation committee to make its final decision. CCGs will continue to receive the outputs and crucial information from the authorisation process at the original time, which means these changes should not have a material impact on the preparations or readiness of individual CCGs to take on their functions on 1 April 2013.

Q: Does this mean that my CCG can no longer discharge conditions once these are set by the NHS CB committee?

A: This additional period of time is not intended to replace or replicate the review of conditions that is planned for March 2013. The review in March (and subsequent quarterly reviews) are the appropriate place for considering conditions that are interrelated, require triangulation of multiple evidence sources, or relate to systemic issues.

Further information

For regular updates on CCG authorisation, sign up for the ‘Bulletin for proposed CCGs’ by sending your contact details to pathfinderlearningnetwork@nhs.net, or view the latest issues online here.

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