interviews

Thirty-two CCGs – one voice

GP Dr Marc Rowland, who chairs Lewisham CCG, has just been appointed chair of the London Clinical Commissioning Council too, which represents all 32 CCGs in the capital. NHE spoke to him to find out his plans in the role.

London’s clinical commissioning groups are going in the same direction – but at different speeds.

That’s the conclusion of Dr Marc Rowland, who on 1 October took over as chair of the London Clinical Commissioning Council (LCCC).

Dr Rowland, already chair of the Lewisham CCG, noted the huge diversity among London’s 32 boroughs and thus the different challenges faced by the various CCGs.

The LCCC’s role is a co-ordinating one, taking in the views of the individual CCGs and reflecting them back to each other and to NHS England, and acting as a single point of contact and – where appropriate – as a single voice.

For example, on the day NHE spoke to Dr Rowland, he had been at the launch of the London Health Commission’s report, ‘Better Health for London’, with Boris Johnson and Lord Darzi.

The LCCC published its own statement on the proposals, welcoming the “practical steps” and “clear aspirations” in that far-reaching report into public health measures on behalf of all the London CCGs – each of which is also free to act on its own and issue its own response.

The CCGs’ longer-term responses and actions following that report will be a key focus for the LCCC in the coming years.

Projects

Other recent and ongoing work programmes tackled by the LCCC have included an ‘acuity project’ looking into the four-hour A&E target across London and better planning for winter 2014-15; improving collaborative commissioning across contracts with providers; reviewing the London levies; enhancing the relationship between the LCCC and London Clinical Senate; and working even more closely with NHS England’s London team, the mayor’s office and London Councils.

One of the key projects has been general practice development. The LCCC provided project managers to groups of GP practices that were considering federating together, four of which were ultimately chosen. Two of these potential federations are large (more than 20 practices each) and two are medium-sized of fewer than 10 practices each. The Open University is analysing the outcomes of these projects.

Dr Clare Gerada, clinical chair of the Primary Care Transformation Programme for the London region, and immediate past chair of the Royal College of GPs, has said that GP federations are the “first real step to integration”.

It is an important issue for Dr Rowland too, who told us: “My predecessor [Howard Freeman] has done a lot of work in helping to facilitate that and co-ordinating information with Peter Kohn, director of the Office of London CCGs.”

Kohn gave NHE an update on that work, saying that once all four federations are up and running, they will “take on a life of their own”, with one of the projects having finished, one almost finished, and two having made changes during the federating process and so still have work to do.

The Office of London CCGs ran a workshop on 22 October for GPs and practice staff working on federation, updating each other on progress, successes and barriers.

Kohn said: “We also looked further to the future and asked ‘how do you win a contract the second time around?’”

Co-commissioning and conflicts

Dr Rowland is also interested in the development of CCG co-commissioning of primary care with NHS England, with implementation beginning in March 2015.

On 10 November, NHS England published ‘Next steps towards primary care co-commissioning’, and its board meeting at the beginning of the month clarified concerns about conflicts of interest, the risks of which are dramatically higher when commissioning primary care compared to other services. To tackle this, the CCG decision-making committees will have a lay, not clinical, majority, and a lay chair.

Dr Rowland said: “Everyone is interested in co-commissioning, but it’s a question of the detail of it and how it works. There is this concept of linking funding together so that it’s much easier to co-ordinate funding and inputs, rather than having separate budgets – but it’s the detail people want to know about.”

London Councils intervened in the debate at the beginning of October, suggesting that local authorities should be able to approve co-commissioning arrangements and that health and wellbeing boards should play a “key role”.

Dr Rowland said he saw the content of the letter from London Councils chair Cllr Jules Pipe to NHS England chief executive Simon Stevens.

Although he could not comment specifically on London Councils’ proposals, Dr Rowland told NHE: “I did see that. I can speak locally, in my capacity as chair of Lewisham CCG; we work very closely with the council, as do CCGs across London. There’s variation in the degree of close working between them all, but in general it’s in our interests to get on, and we have shared desires to improve the health of our population. We each provide very important planks and supports to do that.”

It’s important to avoid conflicts of interest, Dr Rowland said – but also to deal with issues maturely and not be “petty” and start treating everything as a conflict of interest.

“But equally, this is large amounts of public money being dealt with, and we must be as transparent as possible.

“I can’t speak for other parts of the country, where I think there has been much more potential for conflict of interest.”

Pressures

Financial pressures are a theme across the NHS, for commissioners as well as providers. But Dr Rowland thinks that “we’re at an absolute tipping point” in terms of change (he dislikes the over-used word ‘transformation’).

“Talking to people and listening everywhere I go, there is a fantastic will and desire to push on with changes to healthcare and in social care. It’s just a question of whether we can manage to achieve that, because if we can, then the funding problems become less intense. There seems to me to be an agreement – and Simon Stevens has talked about this – that we’ll have to put some funding in to make it work. It’s difficult to see how we’d be able to make all the changes we want to make within our present funding envelopes.”

But cutting into the projected multi-billion pound overspend by 2020 cannot be done “the way things are now”, he said.

Clinical commissioning – 18 months on from the formal transition – is “working very well”, he said.

“I wanted to do a lot of change back in the 1990s and set up a project with the King’s Fund [trying to set up a locality-based primary care service] – which basically failed because I was completely naïve and it was the wrong time.

“PCTs I never felt were terribly primary-care orientated. I did feel they were much more secondary-care orientated and I wasn’t particularly involved – I worked at a slight distance with them, but was not directly on the board.

“The changes now feel much more positive. Having clinicians involved is very good. Could we have achieved that in a different way, by altering the PCT structure? Possibly we could have, but this is the way it’s gone. We aren’t politicians, and we don’t make those choices.

“I speak particularly for Lewisham, but from what I hear from right across London, clinical commissioning seems to be working very well. NHS England has adjusted to these changes very well and I feel very positive about it.”

Dr Marc Rowland

Dr Marc Rowland has been a practising GP for 34 years and is based in Lewisham, where he is a partner of the Jenner Practice and where he chairs the CCG. He was formerly the co-chair of the neighbourhood practice based commissioning group and vice-chair of the Lewisham Federation.

Peter Kohn, director of the Office of London CCGs, said: “We are delighted that a GP leader of Dr Rowland’s experience has stepped forward to lead London CCGs onto their next stage of development. The next two years will see London CCGs’ responsibilities for commissioning extending and maturing and clear clinical leadership will be essential to progress.”

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