From 1 October 2015 local authorities have responsibility from NHS England for the commissioning of health visitor services for children aged 5 and under.
This short guide is intended to clarify the current commissioning structure by looking at the key NHS bodies, their functions and their interrelationships.
The Department of Health, which receives funds from the Treasury including £116.4 billion for 2015/16, sponsors arm’s-length bodies like Public Health England, which is responsible for protecting the population from disease and which works closely with local authorities to reduce health inequalities.
Over 80 per cent of the Department of Health’s total spend is allocated to NHS England. Originally established in October 2012 as the NHS Commissioning Board, this pan-England body is responsible for much of the NHS’s day-to-day strategy and oversees the functioning of the whole commissioning system. NHS England directly commissions health services for people serving in the armed forces and for offenders in prisons, as well as specialist healthcare services for conditions affecting a small number of people. Since April 2015 NHS England has been co-commissioning primary medical services provided by GPs with Clinical Commissioning Groups.
Clinical Commissioning Groups replaced primary care trusts under the Health and Social Care Act 2012. Clinical Commissioning Groups are mostly made up of medical professionals and are responsible for planning and commissioning healthcare services in their local area. The geographical boundaries of Clinical Commissioning Groups, of which there are more than 200 in England, generally match up with those of local authorities.
Clinical Commissioning Groups mainly commission secondary services, which are the provision of healthcare following referral, usually in a hospital, and tertiary services, meaning services accessed by referral from consultants. They also commission ambulance services and community care services. In April 2015, 64 Clinical Commissioning Groups in England took on responsibility for commissioning general practice in their area, with a further 87 beginning a lower level of joint commissioning of general practice with NHS England.
Commissioning Support Units assist Clinical Commissioning Groups in transactional commissioning, for example, data analysis, contract negotiations and market management, as well as transformational commissioning, such as service redesign. Clinical Senates offer specialist clinical advice to Clinical Commissioning Groups.
The commissioned healthcare services are delivered by a variety of providers, many of which may be NHS Trusts or, alternatively, from the private or voluntary sectors.
The Care Quality Commission registers providers against essential levels of safety and quality, and has established a single integrated licensing and registration process with Monitor, the economic and competition regulator for health services in England.
The Care Quality Commission has a statutory committee called Healthwatch England. This national user representation organisation provides advice to the Secretary of State for Health, NHS England, Monitor and local authorities about user views. Healthcarewatch England guidance and support to local Healthwatch organisations, which have been set up to enable citizens to influence and challenge the provision of health and social care services in their local areas.
Under the Health and Social Care Act 2012, local authorities have assumed various responsibilities for improving the health of their local population, such as the appointment, jointly with Public Health England, of a director of Public Health and the establishment of local Healthwatch organisations.
One particularly important responsibility of local authorities is the commissioning of a range of public health services. From 1 October 2015, this includes health visitors for children from birth to 5 years, previously commissioned by NHS England, and local authorities are expected to provide the same level of service at the point of transfer.
The Health and Social Care Act 2012 also established health and wellbeing boards as statutory committees within unitary and upper-tier local authorities. Health and wellbeing boards ensure that commissioning plans meet local needs by leading the development of Joint Strategic Needs Assessments and Joint Health and Wellbeing Strategies. Local authorities must have regard to these when commissioning the relevant services.
Local authorities and Clinical Commissioning Groups may enter into partnership arrangements to commission some services jointly. These are called section 75 agreements, after section 75 of the NHS Act 2006, and are intended to encourage the pooling of money and integration of resources. So far, section 75 agreements have been used particularly in learning disability services and services for children and older people.
Where this commissioning approach is used, lead responsibility for commissioning may rest with either the local authority or the clinical commissioning group.
The Better Care Fund, which went live on 1 April 2015, consists of £5.3 billion, increased from the original pledge of £3.8 billion, to be deployed locally on health and social care through pooled budget arrangements, formalised in section 75 agreements. Health and Wellbeing Boards must jointly agree plans for how the money is to be spent, with the plans signed off by the relevant local authority and Clinical Commissioning Groups.
Further integration between the various component organisations of the NHS is likely. The NHS’s Five Year Forward View, published last year, gives some indication of potential future directions. This includes the removal of barriers between hospitals and family doctors and new models of service delivery, such as multi-speciality community providers. This will inevitably entail more complex partnerships and financial interdependencies, and the contractual approaches to these will need to adapt accordingly to ensure joined-up and seamless services.