8.2 Key sector issues

Background

The government set out significant changes to the structure of the NHS in the Health and Social Care Act 2012. The changes include abolishing PCTs primary care trusts and SHAs strategic health authorities, and increasing GPs general practitioners’ powers to commission services on their patients' behalf by creating CCGs clinical commissioning groups.

The aim of the 2012 Health Act Health and Social Care Act 2012 is to create a framework that puts the NHS on a financially sustainable footing and drives improvements in quality and outcomes. The NHS must release efficiency savings of up to £20 billion by 2014/15, to support improvements in quality and outcomes. This was first announced in the White Paper Equity and Excellence: Liberating the NHS, published in July 2010.

The Commission issued briefings for auditors on the impact of the 2012 Health Act in APBs Audit Policy Briefings (issued by the Audit Commission) 09-2012, in August 2012, and 03-2013, in February 2013. A summary of developments relating to CCGs clinical commissioning groups can be found in section 4 of this guidance.

Timetable for PCT abolition and transfer of functions

PCTs primary care trusts will retain their statutory role for the whole of 2012/13 prior to their abolition, with SHAs strategic health authorities, at the end of March 2013.

Accountability arrangements, based on PCT primary care trust and SHA strategic health authority clusters, will remain in place for 2012/13. PCT primary care trust clusters are accountable to SHA strategic health authority clusters in delivering the requirements of the NHS Operating Framework 2012/13.

The 2012 Health Act Health and Social Care Act 2012 created NHS England (known until 1 April 2013 as the NHS CB Commissioning Board), which will take on PCTs primary care trusts’ responsibilities for commissioning primary care, and certain specialised services. NHS England takes up its full statutory responsibilities from 1 April 2013, with its overall role being to:

• set up, authorise and performance manage CCGs clinical commissioning groups, which will commission most health services for their population;

• directly commission other health services – while CCGs clinical commissioning groups will be responsible for commissioning the majority of healthcare services, NHS England will commission primary medical care services, pharmaceutical services, dental services and specialised services; and

• secure continuous improvement, outcomes, effectiveness, integrated working, public involvement and quality of the patient experience.

CCGs clinical commissioning groups will be responsible for commissioning the majority of healthcare services, including: urgent and emergency care; elective hospital care; community health services; maternity and newborn services; children’s healthcare services; mental health services; and NHS continuing healthcare. Local responsibility for commissioning will transfer from PCTs primary care trusts to CCGs clinical commissioning groups from 1 April 2013.

CCGs clinical commissioning groups began forming during 2011/12, and will be operating in shadow form, with delegated responsibility from PCTs primary care trusts, during 2012/13. They were assessed for formal authorisation by the NHS CB Commissioning Board in four waves, from December 2012 to March 2013. By April 2013, all GP general practitioner practices were members of one of 211 authorised CCGs clinical commissioning groups.

CCGs clinical commissioning groups will require support in undertaking commissioning. The independent, charitable and voluntary sectors are expected to provide some of this support. The NHS defines this assistance as commissioning support. There is no prescribed model for commissioning support, and final decisions on the shape of local support will be a matter for CCGs clinical commissioning groups themselves. Early indications suggest there may be 23 local CSUs commissioning support units established within the NHS to support CCGs clinical commissioning groups.

PCTs primary care trusts are expected to support the emerging CCGs clinical commissioning groups during 2012/13, through agreed development plans, building a track record through management of delegated budgets and financial plans, and developing QIPP Quality, Innovation, Productivity and Prevention plans.

During 2012/13, PCT primary care trust clusters will also be working with local authorities on the transfer of responsibilities for public health. They will also support local authorities in establishing health and wellbeing boards, which will provide local leadership for health, social care and public health improvement.

The 'NHS Operating Framework 2012/13' requires that “… no PCT primary care trust or SHA strategic health authority will plan for a deficit in 2012/13. PCTs primary care trusts carrying legacy debt into 2012/13 must clear it.”

Summary of transfer of PCT functions

PCT clusters

The NHS Operating Framework 2011/12 announced the creation of PCT primary care trust clusters, to create a strong management system for the transition to the new NHS structure, and the abolition of PCTs primary care trusts from April 2013.

The 51 PCT primary care trust clusters need to oversee and account for delivery during transition, and support the development of the new commissioning system. Each cluster is a collection of PCTs primary care trusts with a single executive team. These teams must ensure that each PCT primary care trust in their cluster continues to meet its legal, financial and performance responsibilities and obligations. The chief executive for the cluster is also the accountable officer for each PCT primary care trust in the cluster.

PCT primary care trust clusters are not statutory bodies, and auditors will continue to discharge their responsibilities for individual PCTs primary care trusts for the 2012/13 financial year.

The ongoing changes during 2012/13 may see a loss of corporate memory as responsibilities, staff and resources are redistributed across a range of new bodies, or leave the NHS altogether. PCT primary care trust clusters and individual PCTs primary care trusts may increasingly struggle to retain key and senior staff, and appoint interim staff with the necessary skills and experience to deliver ongoing responsibilities. They may also struggle to support and facilitate the development of new and emerging organisations.

The Commission has previously issued information for auditors on the DH's Department of Health's clustering requirements, in APB Audit Policy Briefing (issued by the Audit Commission) 05-2011.

The Francis Report and the Keogh Mortality Review

The final report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, and the subsequent announcement of the Keogh Mortality Review, have put NHS trusts and FTs under greater scrutiny. Further details have been provided in section 3.2 of this guidance.

PCTs primary care trusts contracted with these bodies during 2012/13 to provide healthcare services to their residents. Where a PCT primary care trust had a significant relationship with a trust, there should have been appropriate arrangements in place for the PCT primary care trust to monitor the performance of the trust in respect of service standards, quality outcomes and cost as part of the PCT's VFM value for money arrangements.

PCT primary care trust auditors may wish to consider the work that the PCT primary care trust has undertaken to assess and monitor the risks facing their significant provider trusts. Where the PCT primary care trust has not assessed and monitored risks effectively, the auditor may wish to consider the impact of this on their VFM value for money conclusion.