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Chapter 3: Should CCGs be scrapped?

Chapter 3: Should CCGs be scrapped?
By Victoria Vaughan Editor
4 July 2022


A post-mortem
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about A post-mortem

Chapter 1
Background: The evolution of CCGs
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about Background: The evolution of CCGs

Chapter 2
CCG successes and failures
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about CCG successes and failures

Chapter 3
Should CCGs be scrapped?
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about Should CCGs be scrapped?

Chapter 4
Clinical leadership: where will it go?
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about Clinical leadership: where will it go?

Chapter 5
What does the future hold for primary care?
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about What does the future hold for primary care?

Chapter 6
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about Conclusion

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about Farewell 

The Health and Care Act 2022 sets in motion the next reorganisation of the NHS. CCGs will be replaced by 42 ICBs – which will have one, two or three primary care representatives, not necessarily GPs. ICSs will work alongside integrated care partnerships, which will bring together the NHS and local councils. 

These IBCs officially kicked off on 1 July but have been gestating as STPs since 2016 . Now they have statutory status and will receive much of the NHS budget, currently about £151.8bn. 

These ICBs will be judged on how well they foster integration. Each area is still working out its structure but broadly speaking ICBs will delegate their budgets to places – usually based on council footprints – and neighbourhoods at PCN levels. 

But many have questioned whether this is the right thing to do and if, after a pandemic, it is the right time. Many of the CCG leaders understandably feel annoyed that CCGs are coming to an end and regard it as a general failure of governance of the NHS. Changes take a long time to work through an organisation as big as the NHS. There is a feeling that rather than reconfigure the service more efforts should have been made to raise all CCGs to the best standards. 

The majority of respondents (49%) say CCGs should not come to an end but a quarter believe they should. See box 6.

Dr Hasan Chowhan, chair of North East Essex CCG, doesn’t think legislation was needed to develop integrated working. 

‘CCGs have been working in the system for quite some time, so although there wasn’t formal integration, many of us have been working in that way. For us in North East Essex, using this model of alliance contracting, we’ve transformed urgent care. We’ve been living it. It’s nice to get the formal sign-off for integrating health and social care, but I don’t think it’s so apparent how that will work. I’m not sure a great deal will change under that integration badge.’ 

Dr Fernandes echoes this sentiment. ‘Everything that the ICS is trying to achieve, we achieved in Croydon because we developed an alliance with the local authority, the mental health trust, the GP collaborative and the voluntary sector. The voluntary sector came in to its own during the pandemic and we built on that. So, we had an integrated system already developing.’

Dr Findlay, who has worked in CCGs since they began, is emphatically against getting rid of CCGs. 

‘The problem is that not all CCGs were good; but instead of making all CCGs good we have another reorganisation. What they should have done was try to make all CCGs as good as the best.

‘I’m a great fan of CCGs. I think they’ve done a lot to develop community services. Durham was doing primary care home (a programme from the National Association of Primary Care) before we had PCNs. We’ve invested in community services and developed integrated services. We’re closely integrated with our council,  voluntary sector and acute trust. We’ve set up joint partnership boards with mental health trusts, the acute sector, local authorities, CCGs and GPs. CDs of PCNs are on them already. So, from a place point of view, we have done everything but set up a formal joint committee and we’re in the process of doing that at the moment,’ he explains. 

He says the move to ICBs is political. ‘It’s hard to understand why [they are getting rid of CGGs]. It’s not going to help integration. If anything, it will make integration more difficult. If they’re not going to make staff redundant, which they’ve said they won’t do, it’s not going to save money. How will it help? I don’t understand,’ he says.

Croydon’s Dr Fernandes agrees. 

‘If we hadn’t had CCGs I don’t think we’d have got through the pandemic as we did because it required a lot of clinical input, clinical leadership and management support. I can’t see how the pre-CCG era could have done that – or a system that is further removed from the front line,’ he says.

Dr Lakhani says he has ‘mixed views’. ‘I agree with the policy direction, but I feel sad that CCGs themselves are coming to an end.’ 

He says CCGs weren’t able to create the change needed as providers captured the market. People needed to be ‘brought together in accountable care organisations – which is what ICSs are’. 

‘Now there is a statutory responsibility for hospitals, GPs and community trusts to work together in a partnership that’s legally defined, for patients. So this is the big change. There’s no procurement, or there shouldn’t be, and there’s no competition. 

‘Forget all the policy. The change we need  is this – when somebody’s ill or thinks they’re ill, there’s a local solution to their needs, and 90% of that should be done [out of hospital].’ 

Dr Lakhani is worried about what the ‘big change’ will mean for GP engagement. He feels CCGs provided a voice for general practice. ‘I don’t think it’s black and white. I think the policy direction is clear because we needed the mechanisms to change services, and the financial packages, but I’m worried the clinical voice that CCGs gave might be diluted,’ he says.

Dr John says CCGs are not ending; rather, they are ‘evolving’.  

‘This is the next stage of CCGs. We’ve got this clinical leadership, we’ve got that historical learning. We’re building on what we’ve learned and trying to improve outcomes even further.’ He adds that the change is also about looking at resources in terms of finances, workforce and estates in a collective way to make long-term plans for population growth and infrastructure changes. 

Dr Gupta is also in favour of the move to ICBs.  

‘Yes [CCGs should come to an end] but there’s a lot of good stuff we mustn’t lose. I’m probably biased when I say this, but the single biggest success of this has been bringing clinical leadership through from primary care specifically.’ 

Dr Gupta fears that while CCGs spent the last decade investing in people who are now skilled and experienced ‘there is no retention and succession planning going on’.

‘There’s a huge risk that, having invested in these people and proved they add value, we then lose a lot of primary care clinical leadership.’

He says that in North Central London, the five CCGs had around 40 GPs in strategic leadership roles. This number fell to 10 GPs on the North Central London board. The ICB has plans for just one or two.  

‘That’s a huge reduction – and what’s become of those 40 leaders? What efforts are being made to retain them in some form? While I don’t think you need 40 strategic leaders, you don’t want to lose them. You want to retain the skills and experience,’ he says. 

Crudely, if that figure of 10 clinical leads per CCG is extrapolated, that would be around 1,000 clinical leaders who have worked at a strategic level. The new system has space at ICB board level for 61, according to the recently published 42 ICB constitutions.  

‘It’s not the clinically led commissioning element that needs to end,’ he says. ‘It’s the commissioning set-up in general that needed to be overhauled. CCGs, as they were constituted, have run their course – because some of the commissioner-provider split has run its course. Putting clinicians into directly adversarial positions is not a good idea.’ 

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