Centralising the NHS – merging Clinical Commissioning Groups

While we have our heads down in the pandemic NHS England is pressing ahead with its plans to reorganise the local NHS landscape. It looks like this involves getting rid of place based Clinical Commissioning Groups and creating sub-regional Integrated Care Systems and locality based Primary Care Networks. Much of this is in line with a blog I wrote 16 months ago.

NHSE has been held back because abolition of CCGs requires a change in legislation – which has been delayed by Brexit and COVID.

Nonetheless NHSE and the Government still appear to be keen to progress this – so instead they are using changes that do not require legislation retaining CCGs but reducing their number through mergers, with the aim of eventually creating a single CCG function that is co-terminus with Integrated Care Systems.

The current state of play is set out in this presentation which includes two examples from Norfolk and Kent showing how CCGs have CCGs have managed the politics of this change with local government and the public.

Although NHS England and the Department of Health and Social Care have said that choosing to merge is a voluntary process and will by decided by local CCGs it is of course possible to ‘encourage’ this by changing the wider environment through a mixture of incentives and pressures – for example:

1. Require CCGs to reduce management costs by 20% by 20/21
2. Claim that CCGS are volunteering to merge into sub regional ICS – in fact many mergers were due to CCGs wanting to become co-terminus with local authorities eg Leeds from 5 to 1 and Bradford from 3 to 1 etc
3. Trying to create single Accountable Officer positions in charge of multiple CCGs on an ICS footprint – which is in effect a precursor to merger.

All of the changes above – taken by themselves can be seen as reasonable and only of internal concern to the NHS, which means that there has been little discussion of the direction of travel outside the NHS with local authorities, the VCS etc.  The risk is that a series of much more important questions are left unasked and unanswered such as:

• What are the challenges facing local health and care systems?
• What are the best ways to mobilise a range of diverse stakeholders (the public, NHS, local government the private sector and the Voluntary Sector) to work together to address these challenges?
• What is best done at a neighbourhood, place, sub-regional and national level?
• What is the best way to hold these different stakeholders to account in order to bring supportive but critical challenge?

Why is any of this important?

There seems to be two assumptions within the NHS England/Government plans

That running the health service is best done at a sub-regional level with an implied belief that delivery of the health services is fundamentally about the management of standardised services rather than co-design of health and wellbeing systems to fit places. There also seems to be a belief that accountability to NHS England or Government is more important than accountability to places.

One of the examples in the presentation claims a range of benefits such as being better at tackling inequalities to justify mergers. This is a dog whistle argument – mention the right areas – but don’t present the evidence for why this is the case. This direction of travel – moving to get rid of place based CCGs to sub regional ones shows a failure to understand the contribution that local governance makes to collaboration and the development of integrated working.

In my experience the involvement of CCG Governing body members (Executive, GPs and Lay members) are key to connecting with the VCS, Health and Wellbeing Boards, Healthwatch, Joint Commissioning Committees  and local authorities. This diversity of stakeholders has helped to build relationships,  sensitise plans and strategies on difficult areas such as inequality, public voice and provided leadership in public meetings connecting citizens and communities to plans.

Second building on the CCG role at place level means that there is a good fit with local authority structures and accountabilities – this is how we do local democracy. It’s not perfect – but it is certainly better than moving everything up to sub-regions. As the paragraph below from the report of the Governments Public Accounts Committee in 2019 in 2019 on CCGs notes:

A similar and wider range of concerns has also been expressed by the British Medical Association in their 2019 guidance here.

What next?

Place based CCG Governing Bodies have either spent the last 7 years or so messing about or have (sometimes painfully) provided an important contribution to the development of local health systems – I think it is the latter! We need to:

• Set out with our local partners why place based governance of the NHS is important.
• Engage with their Integrated Care Systems – and ask the sort of system questions that I sketch out in bullets above.
• Where it does not already happen CCGs, Healthwatch and Local Government should be demanding that Integrated Care Systems have active representation from Local Government and the Voluntary and Community Sector – a good example of this is West Yorkshire and Harrogate Integrated Care System

What do you think?

Declaration of interest – I am a lay member on Sheffield CCG