The NHS Long Term Plan balancing act

Published 11 junio 2019

When he launched the NHS Long Term Plan, NHS England Chief Executive, Simon Stevens, called for the removal of restrictive competition and procurement rules embodied in the 2012 Health and Social Care Act. Will it help?

Clinical Commissioning Groups (CCGs) control around two-thirds of the £125 billion budget for the NHS in England. Their planning and commissioning roles mean that they are pivotal to the success of the NHS Long Term Plan goals of bringing services closer to patients, driving joint working and targeting clinical priority areas. 

In 2013, 211 CCGs were created as a result of the 2012 Health and Social Care Act. But the drive for greater integration and more community-based services has been a catalyst for change. A National Audit Office report from December 2018 reveals major CCG restructuring, with increased joint working and some mergers, in line with the direction of travel in the Plan. At present, there are 195 CCGs, but the Plan envisages just one CCG for each of the 44 Integrated Care System (ICS) footprints across England.

MORE SCOPE, MORE PROBLEMS

DAC Beachcroft Partner and specialist in commercial law, Hamza Drabu, says the move towards one CCG per ICS may have a detrimental impact on integration of health and social care commissioning. “An ICS would generally cover a much greater area than a single local authority. However, the integration of commissioning NHS services and local authority commissioned health-related services successfully, often comes down to locally forged relationships and a deep understanding of the local pressure points in the system."

“It is important that those local relationships are not lost in the move to merge CCGs, as more coordinated health and social care can lead to a better patient experience and in many cases, financial savings to both the NHS and local authorities that can be reinvested into frontline services.”

Julie Wood, the Chief Executive of NHS Clinical Commissioners, which represents CCGs, agrees that local relations are vital. Giving advice to the Commons Public Accounts Committee in January, she said CCGs are trying to work in two worlds at the same time: “The world in which they were constructed statutorily as 195 CCGs. But also, a world that is based much more on collaboration, integration and working at big-system level, as well as critically continuing to work at a local place-based level, so that they can deliver change at both ends.”

NHS England Chief Executive Simon Stevens told the same committee: “Really the question that, pragmatically, has got to be answered by the NHS locally with its partners is: what is the biggest geography that you can have while still retaining the sense of ‘us’?”

Wood feels that it’s all about retaining the right balance between being ‘local’ and being able to operate at scale. “That is the tension that we need to find an answer to as we try to deliver those ambitions. Evidence from our members shows that the best way of trying to address this is from the bottom up, and work from the basis of ‘what do we need to do at a very local level, and what can we do once at a much bigger level and bring together our functions?’ And as those decisions get made – we want to make sure that we keep clinical leaders at the heart of this, as they’re best placed to remember the ‘why’ of the NHS – to improve health for all.”

THREE-TIER APPROACH

Anna Charles from The King’s Fund explains that to retain this sense of ‘us’, action is occurring at three levels, starting at the local 30,000 to 50,000 population level – the immediate neighbourhood, the groups of GP practices – where primary care networks are developing. Then there is what local government calls ‘place’, which is around a few hundred thousand people. Finally, we come to the much bigger ‘system-level function’ at ICS population level (around 1 million), where a lot of the health service planning across hospitals and other services might need to occur.

Charles says ‘place level’ is often where the relationship with local authorities is naturally strongest, because it often matches up to their boundaries. And as local authorities are responsible for social care and public health, their sign-up is vital. “In areas that are working as ICSs, local authority engagement has been variable, with some areas reporting difficulties with local authority engagement over the last few months.”

Charles continues: “Lots of areas have found, or are looking at, ways to bring local authorities more formally into their structures, whether by having a place on the ICS board, by having joint health and wellbeing boards working at the level of the ICS, or joint overview and scrutiny committees. There are various mechanisms that work, but there are lots of obstacles that make it difficult because it all comes from the NHS starting point. Often the ICS is operating at a level above the local population to which the local authorities are accountable."

MEETING TARGETS

One of the additional tasks the NHS has set, are for CCGs to save 20% on operating costs. Some 127 CCGs now have shared management, with 38 senior leaders operating across them. It’s envisaged that many CCGs will end up having one single accountable officer for their ICS.

Some CCGs have gone through formal mergers, but many others are looking to easier and cheaper informal arrangements. Dr Paul Johnson, the Clinical Chair of South Devon and Torbay CCG, describes the local evolution: "Not only did we feel South Devon and Torbay CCG was too small a footprint to commission on, but the acute services we were providing for that community had a lot of co-dependencies with other areas of Devon."

“That is where we started in our working relationship with the rest of Devon – with NHS Northern, Eastern and Western Devon CCG. Through a process that has been 12 to 18 months in the making, we have moved to a single executive team, a single management structure and are sharing committees. The movement to becoming a single CCG across the whole of Devon then becomes a relatively small step and the next logical progression for us."

The merger will mean the mega-CCG can work with the providers for all of Devon, commissioning services for the whole population, rather than commissioning for separate services with the additional complexity that brings. Johnson says that up to the point of merger, £4 million has been taken out of our running costs, and another £1 million will be saved after the formal merger. “That takes us almost up to the 20% target that NHS England has set us.”

To discuss the issues raised in this article, please contact Hamza Drabu.