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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