Commissioning: further issues - Health Committee Contents


5  Authorisation and Assurance of Commissioning Authorities

Authorisation of Commissioning Authorities

81. The Health and Social Care Bill proposes that all local commissioning bodies should be subject to an authorisation process conducted by the NHS Commissioning Board before commissioning authority is vested in them. The Bill envisages that all local commissioning bodies will satisfy the requirements of this authorisation process before 1 April 2013.

82. In her evidence to the Committee on 22 March 2011, Dame Barbara Hakin articulated the criteria against which the Board will assess each consortium before it is authorised to undertake its statutory commissioning functions. The NHS Commissioning Board will make judgements on:

  • the clinical focus of consortia, including but not exclusively GPs,
  • the degree of responsibility to patients and the public,
  • whether consortia have the ability to improve service quality within its available resource,
  • a consortium's ability to discharge its functions,
  • the degree of collaboration with other consortia, and
  • consortia leadership arrangements.[69]

83. Dame Barbara Hakin told us that it is unlikely that all consortia will be ready to assume their full commissioning role on 1 April 2013.[70] As a contingency plan, the Government are proposing that the NHS Commissioning Board may apply different levels of authorisation to consortia, based on the assessment. These include:

  • authorised to commission some services but not others,
  • authorised to commission services but with support, and
  • conditional authorisation.[71]

84. The Committee notes that Dame Barbara anticipates that it is likely that authorisation will be a process rather an event, with the result that there will be a phased implementation of the changes to NHS commissioning, rather than a big bang. The Committee strongly endorses this approach.

85. In view of this change of policy emphasis the Committee was interested to establish the statutory basis on which this phased implementation would be carried out. The services that consortia are not authorised to commission will have to be commissioned by some other body. Dame Barbara told us that neighbouring consortia or the NHS Commissioning Board could undertake these functions whilst consortia developed their working practices in order to become fully authorised.[72]

86. In earlier evidence Dame Barbara had said:

    The Board will have a number of options where it feels a consortium doesn't meet all the criteria set out in the eventual authorisation process. First, it could confer partial authorisation on the consortium. It could choose to say, "For these services, which are slightly more straightforward to commission, we are happy for the consortium to commission them." But the Board itself, or another more effective consortium, might, in the short to medium term, take over the commissioning of the more complex services.[73]

87. This answer implies that the NHS Commissioning Board will have a wide range of discretion about the pace and extent of authorisation of individual local commissioning bodies. It is important that there are powers in the Health and Social Care Bill to allow the NHS Commissioning Board to manage this process effectively.

88. The Government has repeatedly stated that its proposed reforms consist of three mutually reinforcing parts:

  • no decision about me, without me;
  • an increased focus on outcomes; and
  • the principle of assumed liberty rather than earned autonomy.[74]

89. In contrast to the third of those elements, Dame Barbara told the Committee that the principle of "earned autonomy" will inform the authorisation of local commissioning bodies.[75] The Committee supports this change from the principle of "assumed liberty" to one where commissioners will earn autonomy, and are only authorised to commission once the NHS Commissioning Board is satisfied that they are competent and capable.

90. Authorisation of consortia will clearly be very different to the process for authorisation of Foundation Trusts (FTs). The King's Fund told us that:

    In stark contrast with the authorisation process […] for aspiring Foundation Trusts, consortia will be new organisations with no track-record they can be judged against.[76]

91. NHS Trusts applying to become FTs will have been trading for many years before their application and have established executive teams, networks and relationships with stakeholders. Sir David told the Committee that in the absence of "several years of trading" data the authorisation process for consortia will "have to be based on perspective".[77]

92. In evidence, Sir David Nicholson told us that:

    I would like to see, as a principle, a 360o part of the process so that patients […], local authorities, secondary care clinicians and other clinicians would be able to have their say in relation to the authorisation of that organisation.[78]

The Committee welcomes Sir David's commitment to consult all stakeholders during the authorisation process.

Annual Assurance

93. The Health and Social Care Bill stipulates that the NHS Commissioning Board must conduct an annual assessment of consortium performance,[79] sometimes known as commissioning assurance. Commissioning assurance will focus in particular on how a consortium is performing against its duty to secure the continuous quality improvement of health services.[80] The Board must have regard to the NHS Outcomes Framework in this assessment and any commissioning guidance issued.[81] The Board can require written or oral explanation of any matter relating to how consortia are exercising their functions and it must publish its assessment of the performance of consortia.[82] The Board will take the views of relevant Local Authorities and Health and Wellbeing Boards into account in its assessment of each consortium.[83]

94. In its evidence to the Committee, the Royal College of Nursing told us that the Health and Social Care Bill has "insufficient detail around assurance and governance [of consortia]".[84] Other organisations such as the BMA and the NHS Confederation have also expressed some concern about the level of detail available on this matter.

95. In her evidence to the Committee, Dame Barbara Hakin told us that the assurance process for consortia had not yet been decided and that the Board must have confidence that consortia can come together and develop "consistent commissioning plans across a wider, broader geography".[85]

96. The King's Fund has told the Committee that they support the idea of an annual assessment process but suggests that this needs to be an opportunity for development as well as an annual assessment of achievement. It suggests that:

    An assessment of core commissioning competencies would be of much value to consortia, particularly in the early years when they are developing skills and capacity.[86]

97. As part of the Labour Government's World Class Commissioning system, all PCTs took part in an annual assurance process that measured their progress against achieving specific health outcomes, against core commissioning competencies as well as assessing their governance arrangements and the performance of their Board.[87]

98. In his evidence to the Committee, the Secretary of State highlighted a key issue with regard to consortium failure.

    It is the Board's responsibility to identify that prospect of failure and to intervene early, not to wait around for a failure to occur. We have had too many instances of waiting around for failures to occur.[88]

99. The Committee was struck by these comments, in that we assume that the annual assurance assessment will take place at a fixed point in the year. The NHS Confederation echoed this, and they have expressed some concern about the period between annual assessments.

    The Bill sets out a clear intervention regime for consortia that are failing or deemed at risk of failing, but there is no indication of how performance is monitored and managed prior to that point.[89]

100. The Committee acknowledges the need for authorisation and assurance processes for local commissioning bodies, and for intervention by the NHS Commissioning Board when things are going wrong. However, these processes will be resource-intensive and require local knowledge that a national body may not possess. We recommend that when the PCT clusters become outposts of the Board in 2013 that their resources be directed towards authorisation, assurance and support of commissioning bodies.

101. Given their role in authorising and assessing local commissioning bodies, and their powers of intervention when commissioners are failing or likely to fail, the outposts of the Board have all of the characteristics of performance managers. The Committee welcomes the presence of performance management in the commissioning process and believes its role should be strengthened by requiring local commissioners to have regard to Support and Improvement Plans developed by or with the outposts of the Board.


69   Q 484 Back

70   Q 484 Back

71   Q 484 Back

72   Ibid. Back

73   Q 254 Back

74   Cm 7993, paras. 1.2, 4.76, 7.10, Cm 8009, para. 8 Back

75   Ibid.  Back

76   Ev 139 Back

77   Q 249 Back

78   Q 249 Back

79   Health and Social Care Bill cl.14Z1 Back

80   Ibid.  Back

81   Health and Social Care Bill. cl. 14Z2 to 14Z5  Back

82   Ibid. Back

83   Cm 7993, para 4.56 Back

84   Ev 147 Back

85   Q 473 Back

86   Ev 139 Back

87   "World Class Commissioning", Department of Health website, 7 April 2010, www.dh.gov.uk Back

88   Q 476 Back

89   Ev w9 Back


 
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Prepared 5 April 2011