CCGs are at the heart of our NHS modernisation plans, said former health secretary Andrew Lansley nearly six years ago at the launch of draft guidance when CCGs were just emerging.
His vision was that CCGs would ‘put healthcare professionals in the driving seat so that they have the freedom and responsibility to design services on behalf of their patients – delivering better quality and integrated care.’
Six years on and CCGs were just starting to get to grips with their job description. In the Five-Year Forward View, CCGs were invited to take on more responsibility for general practice through primary care co-commissioning. By April 1 2017, 176 CCGs out of 209 had taken on full responsibility for the commissioning of GP services. The remit of CCGs seemed to be growing.
But faced with rising demand and rising deficits, NHS England decided to shift its focus away from siloed working and onto integrated care, which the organisation deemed better for patients and more financially efficient. England was divided up into 44 sustainability and transformation plans (STPs), around half of which are led by local authority or trust chief executives, and encompass all aspects of health and social care.
It seems, instead of being the ‘safeguard’ against an ‘aging population and the increasing costs of treatment’, as Mr Lansley put it, that CCGs have become a cog in a larger machine.
At a recent NHS England board meeting, Simon Stevens, head of the organisation, said STP leaders would be given more ‘decision rights’ that allow them to ‘recommend changes to the configuration or governance of constituent statutory organisations’ – including CCGs.
Furthermore, several STPs have proposed setting up accountable care organisations (ACOs) to look after the budget for integrated care systems, like vanguards, that are also in the works, relieving CCGs of some financial responsibility. Does this spell the end of an era for CCGs?
In Lancashire and South Cumbria, health and social care leaders are looking to set up five local delivery plans, either as ACOs, accountable care systems or multispecialty community providers (MCPs). Any of these, says Andrew Harrison, financial officer for NHS Fylde and Wyre CCG, could turn the CCG into a ‘shell organisation’.
‘If you end up with a successful accountable care organisation, or a successful MCP, a CCG becomes a bit of a shell organisation,’ says Mr Harrison.
In NHS Fylde and Wyre CCG, Mr Harrison says there are plans to set up an MCP on the Fylde coast with an accountable care system –
a more loosely affiliated version of an ACO – to look after the area’s existing providers as well as that MCP.
But, he says, even though CCGs may be reduced to their shell, there will still be a strong primary care voice. ‘The same aspirations and desires of a CCG, as a GP primary care-led organisation, would be better fulfilled, in my view, by an MCP on a joint basis with secondary care clinicians through an ACO,’ he says.
While Mr Harrison says that CCGs aren’t likely to be officially dissolved anytime soon, as the Government focuses its legislation on Brexit in the coming years, the organisations are likely to lose control over their financial arrangements as more local care delivery systems are set up. ‘So the definitive answer is that a CCG would lose all control because there’s nobody in it doing anything’, he says.
Whether that’s a good thing or a bad thing depends on your view of wider STPs, he says. ‘I do like the idea that neighbourhoods and MCPs will have control over their finances,’ he says.
But, he adds: ‘The opportunity to share best practice across wider boundaries than just CCGs is the benefit that the STP brings. Whether you call that losing control or taking advantage of best practice depends, I guess, which side of the fence you sit on.’
CCGs in name only
Ruth Robertson, a health policy fellow at the King’s Fund think-tank, echoes Mr Harrison’s suggestion that a well run ACO could leave a CCG with ‘nobody in it’.
She says CCGs in areas with ACOs have ‘stepped back’ to a more strategic planning role and much of the day-to-day commissioning work originally done by the CCG has been taken over by the ACO.
CCGs instead, she says, will be left to ‘set the broad direction of travel’ and set targets for the ACO to hit. ‘The ACO will then decide which providers they’re going to work with or how they’re going to deliver and that may involve contracting and performance management by the ACO,’ she says.
As the majority of commissioning work shifts to an ACO, ‘we may start to see some staff shift if that happens’, she adds.
Ms Robertson emphasises that the rate at which these changes will happen will vary across the country. However, following NHS England’s announcement that some STPs would be set up as accountable care systems from April this year, Simon Stevens has lit the ignition to set up ACOs across the country. The Next Steps on the Five-Year Forward View notes that all accountable care systems will become ACOs ‘in time’.
While CCGs are ingrained in the Health and Social Care Act 2012, they will soon be the CCGs envisaged by Lansley in name only. Ms Robertson says: ‘Their shape may change. Their geographical footprint and their role may change.’
Fewer, larger CCGs
Many CCGs have started to change their shape already. To cope with demand, commissioners are choosing to work on a larger scale by pooling their resources and talent with neighbouring regions.
The three Manchester CCGs plan to merge in April this year, and Birmingham, which also had three CCGs covering its 1.2 million population, will have just one by April next year.
While the concept of merging is not new (the first was in 2015, when three CCGs in Newcastle joined forces), Simon Stevens put an informal ban on the tactic shortly after becoming NHS England’s chief executive.
In February that ban was lifted, resulting in a wave of applications from CCGs looking to combine, but on the condition that the new combined CCG serves the wider STP by providing ‘a logical footprint’ for its delivery.
The most recent areas to consider merging, NHS Liverpool, South Sefton, and Southport and Formby CCGs, will create the largest CCG in England if the merger goes ahead in April next year, with a budget of £1.2bn in 2018/19.
Dr Nadim Fazlani, chair of NHS Liverpool CCG, said the areas’ commissioners are considering merging because ‘we’re very unlikely to have the resources, each of us on our own, to engineer the changes we are going to need in the next couple of years’. The three CCGs have already been working closely together for many years, first as primary care trusts and now as part of the north Mersey area of the Cheshire and Merseyside STP region.
While he says it ‘is a concern’ that having one CCG instead of three in STP discussions with trusts and local authorities could dilute the voice of primary care, Dr Fazlani adds that ‘it is something that we have to work with’ in order to deliver care at the right population size.
‘What is important is the right footprint to make the decisions in terms of population,’ he says. ‘When you are working across a large trust that spans multiple CCGs you have to find a way of bringing the CCGs together, otherwise the decision-making becomes very fragmented.’
The Cheshire and Merseyside STP included plans for the north Mersey area to deliver care through ‘integrated multi-disciplinary teams’ including general practice, community nursing, mental health and social care among others for 30-50,000 people – something the three CCGs can do better if they merge, says Dr Fazlani.
‘We are creating something that is at a bigger footprint but also something that is at a smaller footprint,’ he says. ‘We have to accommodate both of them because otherwise we’re not going be able to care for what is quite a diverse population.’
Dr Fazlani adds that this will cause a functional change for CCGs as they make decisions on both a smaller and larger scale than before. He says, though, that it’s unclear whether that’s because of patient demand or STPs. ‘Is the STP a forum for discussion or is it going to become an entity on its own? I think the jury is still out,’ he says. ‘We may be making too much of STPs.’
What is an ACS?
An accountable care system (ACS) is formed when commissioners, providers and local authorities sign a loose agreement, usually a memorandum of understanding or an alliance agreement, to take on a ‘collective responsibility for resources and population health’, according to NHS England. Unlike an ACO, organisations within an ACS keep their individual status.
In NHS England’s Next steps on the Five-Year Forward View, released last month, it was announced that all STPs will eventually become ACSs following a staged implementation. Nine areas were announced as likely candidates to take on ACS status from April this year. The areas are:
The document described the transition from STP to ACS as ‘a complex transition’, requiring ‘careful management’ to reduce instability and manage risk. It added that ‘in time’ some ACSs may become ACOs ‘where the commissioners in that area have a contract with a single organisation’ for most of the healthcare services in the area.