Verita is increasingly being asked to undertake investigations into governance arrangements and practice in CCGs. From a number of recent investigations, we have identified some key themes which contributed to the failure and are likely to be common issues for other CCGs.
- The responsibility for primary care commissioning was moved centrally to NHS England when CCGs were formed, however, CCGs retained some responsibilities (e.g. for LISs/LESs). As there was a lack of clarity about the level of involvement CCGs would have in primary care commissioning some did not put in place fully staffed, substantive teams. This has resulted in a lack of a consistent, substantive workforce which has the potential to undermine the ‘organisational memory’ of some CCGs. Few permanent substantive staff and a succession of interims, often in senior positions, can be problematic not just from an operational perspective, but also because it hampers the development of ‘behavioural norms’ that are understood (and adhered to) by staff across the function.
- The inherent tension in the design of CCGs whereby GP’s are explicitly tasked in both specifying local services and delivering them is a strong theme in recent CCG investigations undertaken by Verita. It is clear that at a point in the process GPs must step aside when commissioning (i.e. financial) decisions are taken from which they may benefit. What is considerably less clear is when, exactly, they should leave the decision making (or, indeed, influencing) activity. Given this lack of clarity, it is very easy for individuals with different interpretations of the boundaries of propriety to take exception to behaviour that others may find unremarkable. This is closely tied in with another theme – the ability and empowerment of staff to challenge and escalate behaviours that are troubling to them. This again lacks clarity – GPs were put in charge of running the local NHS, when should non-clinicians challenge them?
- Even where clear policy and guidance exists, our investigations have identified many examples of where practice does not align with policy. This is an issue around governance arrangements and structure, which can be compounded by the lack of a suitably qualified and experienced individual on the CCG governing body to manage issues such as corporate governance. This is manifest in, for example, poor administration within the Primary Care Commissioning team around even vital documents. We have also identified cases where the necessary contractual paperwork was not in place between the CCG and GPs for a number of schemes that were being paid for by the CCG. Valid contracts must govern all schemes and payments must not be made without supporting paperwork.
- In a recent investigation, we found an inconsistent interpretation amongst the staff of what constitutes a conflict of interest and therefore what should be declared. This suggests that either the CCG is not appropriately communicating or monitoring the implementation of the declaration of interest policy or there is wilful non-compliance on the part of GP’s (and other governing body members). The message about the need to declare all conflicts (potential or real) in line with policy needs to be clearly communicated to staff and rigorously enforced.
- There’s a real risk of overlap between core GMS/PMS contracts and enhanced schemes (LISs/LESs) if they are not carefully ensured to be complementary. CCGs need to have a clear understanding of the parameters of the core contract versus the benefits of an enhanced service.
- Another issue identified through a recent investigation is whether LIS payments are eligible for superannuation. This was a difficult issue to get to the bottom of – with conflicting views amongst CCGs about whether they were in fact eligible. NHS England’s advice was that LISs are not pensionable and if CCGs sent all proposed schemes to them in advance of being implemented then this issue would be identified.
- Internal audits are an important way to assess how successful a function is within a given service, whether processes are followed and embedded and whether there are gaps in the system. A recent investigation found that internal audits had been delayed for long periods for several reasons – one being insufficient evidence to share with the audit team. We are, of course, unsure what the audit would have identified if it had happened in as planned, but it is a reasonable assumption that (at least) some of the issues identified during our investigation would have been recognised.