Distrust and pragmatism inform softly-softly authorisation plan

It says: “Neither PCT clusters nor any successor outpost of the [NHS Commissioning] Board… will be involved in the decision about authorisation of local CCGs.”

In other words, local managerial knowledge will apparently count for nothing when making a judgement about the readiness of commissioners – despite the fact that, in many respects, managers will be in a good position to gauge both likely commitment and competence.

HSJ suspects the commissioning board HQ will find ways to use the grapevine to ensure it is educated about any local quirks and issues, but it cannot admit it.

We all know why the Department of Health is having to tread so softly. The GP population as a whole is still not sold on the idea of taking the commissioning reins. The enthusiasts are desperate for the government not to scare the horses with an approach which can be labelled by this sensitive group as prescriptive or bureaucratic.

The frankly outrageous decision to allow GP practices to opt out of the new primary care data scheme is another example of the government’s kid gloves approach. Imagine if a similar opt-out applied to hospital trusts in this post-Mid Staffordshire world.

Although it will only take about 10 per cent of GPs, perhaps less, to become actively involved in CCGs to make them operational, they will need the support of colleagues. Active collaboration in addressing issues such as the rise in referrals is needed – although grudging acceptance will probably suffice in the short term.

The first stage of the authorisation process taking place this autumn is largely designed to prevent unsustainable CCGs being established and concerns structures rather than responsibilities. The second “establishment” stage due in about 12 months is focused on developing rather than testing the emergent CCGs. The government’s authorisation plan is to give enthusiasts the maximum possible space in which to gain confidence and convince colleagues. National director for commissioning development Dame Barbara Hakin is very keen that CCGs focus on what they will do, rather than the details of how they will do it.

It is not just medical politics that drives this approach. Commissioning board chief executive designate Sir David Nicholson wants to heed the lessons of foundation trust authorisation. Rather than repenting rushed decisions he wants to ensure CCGs are as robust as possible when eventually authorised.

Robust they will have to be if they are to reach 2013 successfully demonstrating competence in all six of the proposed “domains” set out in the authorisation proposals. Reducing the danger of having to strip CCGs of some of their powers – or even de-authorise the worst performers – as a result of the first annual check of their competence during the run-up to the next election is a major driver in shaping the graduated approach to authorisation.

In the short term, however, we can expect much more prescriptive action on the development of commissioning support for CCGs. The authorisation guidance declares: “Even the largest CCGs will be unable to undertake the full range of commissioning functions in isolation. Commissioning support is probably the biggest issue… in terms of the development of the new system”.

The DH wants commissioning support organisations up and running as soon as possible and is developing a tough accreditation process to ensure that they form an effective safety net for developing CCGs. There will be complaints about central control and lack of responsiveness, but even the champions of GP commissioning will be, partly, relieved if CCGs slot into an effective infrastructure.