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A new world

It’s an awkward time to be an NHS commissioner – with the 2012 Lansley reforms gradually being pulled from under their feet.

The NHS long-term plan envisages a huge reduction in the number of clinical commissioning groups, along with a significant narrowing of what they are tasked to do.

One of CCGs’ key functions – to choose when to let a contract and which providers to give them to – is becoming surplus to requirements as the NHS aims to foster collaboration between services, rather than competition.

Some CCGs are adjusting reasonably well to the new world, which demands better communication, strong relationships, and strategic thinking.

Others less so.

Warrington and Halton, which operate with a shared management team, are both rated “good” by NHS England. So, they must have been doing some things right.

But there have been a series of instances over the last year which suggest they are struggling to adapt.

GP fall out

In September last year, more than half the GP practices in Warrington said they had lost confidence in their CCG leaders, citing “disappointing behaviours” from accountable officer Andrew Davies and former chair Dan Bunstone (themselves GPs in the borough).

Tensions had been bubbling away for several years due to accusations over the use of more than £4m of transformation money awarded by NHSE, but spilled over when another GP was removed from the governing body.

Dr Bunstone eventually stepped down in January, but Dr Davies has stuck around.

Strained relationships with acute providers then came to a head earlier this year. The decision was made to put the contracts for two NHS-run urgent treatment centres in Halton out to tender, and then name a Yorkshire-based private provider as the preferred bidder.

Dr Davies argued that performance and quality had been poor but, whether this was fair or not, the CCG seemed to misread the politics. It came under heavy fire from local MPs and the council, and when the acute trusts threatened to take legal action against the decision, the CCG backed down.

The procurement process has been “suspended” since July, but seems unlikely to be re-booted. Keeping in line with the national direction of travel would more likely mean local GPs running the UTCs in partnership with the acute trusts.

Opting not to retender could potentially open the CCG up to legal action, but that might look a preferable option to continued division with important partners.

Council fury

Meanwhile, the governing bodies of the two CCGs have been trying to merge with each other, sparked by the need to cut running costs by 20 per cent.

But this has infuriated Warrington Council, whose leader Russ Bowden wrote a fairly uncompromising letter to regional director Bill McCarthy (which has found its way into the local press) criticising the move and a perceived absence of consultation.

The council, perhaps unsurprisingly, wants its CCG to be merged into its own structure, à la the Greater Manchester model. Tellingly, the Labour leader suggested this was also the preferred option of the local provider alliance.

Merger failure

In the event, the council needn’t have worried, as they weren’t the only ones who didn’t like the plans. To go through, the proposal had to be approved by a majority of GPs in both boroughs, and while this was achieved in Warrington, only a third of doctors in Halton backed the management.

It’s not quite clear why the CCGs didn’t ensure they had the support before attempting to push the plans through.

Councillor Bowden then wrote again to the regional directorate, saying he had witnessed “further behaviour” from Dr Davies, and added: “I wish to put on record that this council has no confidence in the current leadership of the CCG and requests that NHS Improvement now acts to replace them.”


Competency review

So, what happens now? Well, following a discussion with NHSE, the CCGs have agreed to commission an independent review of Warrington’s governance and engagement, including “probity and competency”.

It’s not been confirmed who will conduct this review, but there’s an established national programme for assessing CCG capabilities, run by PwC.

Meanwhile, there will be increasing pressure for commissioning to be scaled up on a far larger scale than just Warrington and Halton.

The direction of travel is probably to move from 12 CCGs in Cheshire and Merseyside, to three “strategic” commissioners (with other non-“strategic” commissioning functions transferred to providers). Warrington and Halton will surely need more scale, which would most likely bring it together with St Helens at the very least.

Across the rest of the huge Sustainability and Transformation Partnership, Cheshire’s CCGs have proposed a merger, leaving Liverpool to perhaps join with neighbours in an expanded “city region”, but what of notoriously-independent Wirral?

Blackpool dis-appointments

Talking of relationships, Pearse Butler, the chair of Blackpool Teaching Hospitals Foundation Trust, managed to infuriate some local stakeholders with his approach to appointing Kevin McGee as substantive chief executive.

Last year, Gordon Marsden MP highlighted what ministers described as “irregularities” in the appointment of Mr Butler himself, and he was therefore demanding a by-the-book process when it came to replacing Wendy Swift as CEO.

So, you can understand his disappointment when a process to recruit a substantive replacement for Ms Swift was abandoned in the summer, and Mr McGee (who had been doing the job on an interim basis), was subsequently asked to run Blackpool permanently as well as East Lancashire Hospitals Trust.

There are some obvious reasons why this approach was taken. Blackpool was in a dire state when Ms Swift stepped aside (this has now been recognised by an “inadequate” rating for leadership), and top chief execs will not have been clamouring for the job.

There is also a clear need for trusts to collaborate more effectively in Lancashire, with drastic changes needed to address financial problems.

But these arguments have obviously not been made convincingly enough to Mr Marsden, who decided to vent his frustration during an adjournment debate in parliament last week.