The commissioning system analysed: Spending, staffing and leadership by numbers
- Clinical commissioning groups significantly upped their spending on GP services, even before co-commissioning began
- CCGs spent a lot more on consultancy in 2014-15, as they embarked on major projects
- Commissioners’ spending on non-NHS bodies grew by 14 per cent, and social care providers appear to be one of the big and growing recipients
- Some CCGs have virtually no staff. But overall CCG staffing increased, partly at the expense of commissioning support units
- More than four-fifths of CCGs have more non-GPs on their governing bodies than GPs
Dave West and Rebecca Thomas
Clinical commissioning groups significantly upped their spending on GP services, even before co-commissioning began
- CCGs increased investment in GP services in 2014-15, growing from a low base in 2013-14, their first year of operation
- Taking into account NHS England, which was responsible for core GP services, overall funding for GP services rose slightly in 2014-15, but once again failed to grow faster than other areas
- CCG spending on GPs will leap up in 2015-16 due to co-commissioning. But overall GP spending has to contend with continued pressure to fund rising demand in the acute sector
Clinical commissioning groups' spending on GP services grew by a substantial 31 per cent from 2013-14 to 2014-15.
The reason was not CCGs taking over responsibility for core GP services under “co-commissioning” arrangements, because this did not come into force until April this year. In 2013-14 and 2014-15 CCGs were responsible for GP “enhanced services” and any other services or payments beyond the core contract which they wanted to arrange with GPs.
Instead, there were three main reasons. The first, most interesting one, is CCGs have begun making decisions to shift resources into primary care. Several of those with the biggest increases told HSJ they had decided to expand these services.
Wyre Forest CCG, whose spend on GP services increased by 59 per cent from 2013-14 to 2014-15, making it one of the largest spenders relative to its budget, said: “This increase in spend reflects the CCGs commitment to primary care and can be attributed to [its Putting Patients First strategy], including the development of local contracts with primary care with a focus on admission avoidance schemes.”
The CCG increase was also driven in part by NHS England 2014-15 national planning rules, which encouraged groups to spend more on GP “enhanced services”.
The final reason for the size of the increase is that CCGs’ GP spending was artificially low in 2013-14 - they had just been established and some of their contract responsibilities took a while to be set up or to be allocated to the correct commissioner in the new system.
The five CCGs that spent the largest proportion of their budget on GP services
|CCG||GP spend as a % of total services spending 2014-15||% change 2013-14 to 2014-15|
|North Derbyshire CCG||1.9||8.7|
|Wyre Forest CCG||1.9||59.4|
|City and Hackney CCG||2.6||96.0|
|East Surrey CCG||1.8||248.6|
For many commissioners, shifting resources to new services in primary care was a key purpose of CCGs which, according to law and their own constitutions, are controlled by GP member practices, even if it does not always feel like this in reality. However, at the same time, these signs of them rapidly moving resources to general practice might worry those who see a problem with the conflict of interest.
Acknowledging this issue, City and Hackney CCG, whose large increase was due to non-recurrent investment in out of hospital care, told us: “All decisions of funding to primary care are made under the CCG conflicts of interest policy which precludes GPs from involvement in awarding contracts to primary care.”
Despite the growth on the previous year, the £447m CCGs spent on GP services in 2014-15 was a small fraction of the amount spent by NHS England (the national body remained responsible for core GP services across the country).
However, it was the increase in funding from CCGs that delivered an overall cash increase, as NHS England’s spend fell slightly from £7.27bn in 2013-14 to £7.26bn in 2014-15. Commissioners’ total spending on GP services, according to NHS England accounts, grew by just £186m (2.3 per cent). This was not enough to keep pace with the rest of the NHS, or with the Department of Health’s total recorded spend. As a result, GP spending fell slightly as a proportion of both.
Yet again in 2014-15, and despite CCGs’ investment, there was no major shift towards expansion of GP services or slowing of hospital activity growth. Growing GP services relative to other areas will continue to be difficult when there is huge pressure to fund increasing activity and workforce costs in acute hospitals.
NHS England acknowledged in its annual report that it had “been necessary to defer some planned investments in primary care” to offset its overspending on specialised services in 2014-15. Asked about the overall trend, the national organisation suggested we await a Health and Social Care Information Centre publication later this year which will more carefully evaluate general practice spend in 2014-15.
The trend for CCGs rather than NHS England to fund GP services will see a step-change this year as many groups take on formal co-commissioning powers. Others will do so next year. Commissioners will hope to see a bigger overall jump in primary care spend this year, with various national initiatives to fund expansion and more evening and weekend services, but will again have to contend with the need to fund growing acute care demand and pressure to reduce NHS trust deficits.
CCGs spent a lot more on consultancy in 2014-15, as they embarked on major projects
- Consultancy spending leapt up in 2014-15 as CCGs began major projects
- Tough new controls mean they are now looking elsewhere, or circumventing the rules
Accounts show CCGs steeply increased spending on consultancy services and “other professional services excluding audit” between 2013-14 and 2014-15. Consultancy spend grew by 52 per cent from £74.6m to £113.5m. The difference between consultancy and “spending on other professional fees” is not well defined, but the latter includes things like some legal services. This grew from £43.5m to £52.3m - up 20 per cent.
This does not include spending on commissioning support units, although much of the work CSUs do on service redesign could also be considered to be management consultancy.
These large increases reflect CCGs, in their second financial year of operation, reaching the point of wanting to instigate major projects, so deciding to pay for work on service change or tendering, for example.
Five CCGs with the biggest cash increases in consultancy spending between 2013-14 and 2014-15
|CCG||Cash increase in consultancy spending 2013-14 to 2014-15|
|Central London (Westminster) CCG||£15.5m|
|Tower Hamlets CCG||£5.4m|
Most of the CCGs with large growth in consultancy spend had commissioned major service change work on behalf of a group of CCGs. Although the spending is not attached to a single CCG, it shows the national growth reflects an appetite to initiate big projects as CCGs got up to full speed. This took place even in the year running up to a general election, something which normally delays NHS work on major service change.
Central London CCG told HSJ: “The NHS in north west London has embarked on a significant transformational change programme that involves improving our hospital, community, mental health and primary care services. Central London CCG… acts as the host ‘employer’ for the consultancy resources that have been brought in to contribute to this work by providing additional specialist support and advice.”
The government has put in place tough controls on consultancy spending in 2015-16, so recorded consultancy spending can be expected to go down. CCGs will have to either find different ways to support some of these types of projects, or methods of securing consultants’ help which get around the new rules.
Commissioners’ spending on non-NHS bodies grew by 14 per cent, and social care providers appear to be one of the big and growing recipients
- Commissioner non-NHS spend grew by 14 per cent in 2014-15, partly attributed to accounting changes. It now represents 9 per cent of total DH spend or 12 per cent of NHS commissioner spend.
- Figures from a handful of CCGs suggest as much of their spend in this category is on social care as acute or mental health. Social care may be a growing recipient.
A handful of CCGs published a breakdown of their spending on non-NHS providers in 2014-15 for the first time (see chart above). The information is from a small sample, and it is unclear how reliable it is, so should be treated with caution. But if correct, it indicates that spending on social care accounts for more or less the same proportion of NHS commissioners’ spending on the independent sector as acute or mental healthcare.
Five CCGs with the biggest proportionate increase in spend on non-NHS bodies
|CCG||% change in spend on non-NHS bodies, 2013-14 to 2014-15|
|Aylesbury Vale CCG||156%|
|Nottingham West CCG||45%|
Social care may also be the quickest growing area, with the NHS taking an increasing role in these services, working more closely with local authorities, and being in better financial health than them. NHS England accounts attribute the overall increase in commissioner spend with “non-NHS bodies” (up 13.7 per cent to £11.6bn) to “improved coding… along with a significant increase in the funding for the purchase of social care and from independent providers”.
Several of the CCGs with the biggest increases concurred with the “coding” comment - Aylesbury Vale said its increase was “largely due to a technical change”.
However, some of the increase represented new business for healthcare providers. Bedfordshire CCG’s increase was due to its employing Circle Health as a lead provider for musculoskeletal treatment, although, it pointed out to HSJ, much of this was subcontracted back to NHS providers.
Overall, non-NHS spending figures in NHS England and DH accounts are slightly different but both show the proportion of total spend going to non-NHS bodies is increasing - now at 9 per cent of DH expenditure and 12 per cent of NHS commissioner spend.
These figures suggest non-NHS spend has been growing fairly quickly. It is unclear if this will continue. The NHS is currently under pressure to help keep NHS provider deficits down, and there is little being done nationally which might encourage private sector. That said, there will be a growing need for the NHS to fund social care and support services, which are not normally provided by public bodies. This will be reinforced in 2015-16 by the full implementation of the better care fund, which makes it likely more NHS money will go into social care this year.
Some CCGs have virtually no staff. But overall CCG staffing increased, partly at the expense of CSUs
- There is large variation in CCG staff numbers; 17 had fewer than 20 employees in 2014-15
- Overall, CCG employee numbers were significantly up in 2014-15, while CSUs had fewer staff
- There are forces pushing CCGs to grow, and competing forces suggesting they may shrink
Staff numbers are a good illustration of the variation in how CCGs work. The average number of employees during 2014-15 was 67, but 17 groups had 20 or fewer staff, and four had more than 200.
Ten CCGs with virtually no staff
|CCG||Average employees (headcount) 2014-15|
|Newbury and District CCG||4|
|South Reading CCG||4|
|North and West Reading CCG||5|
|Hartlepool and Stockton-on-Tees CCG||17|
|North Lincolnshire CCG||17|
|Surrey Heath CCG||17|
|Wyre Forest CCG||24|
Some of the very light CCGs simply cover very small areas such as Corby and Surrey Health. More often they share substantial staff with neighbours (and they are counted against other groups) or buy much more than others from their CSUs. A small number may share resources with local authorities.
The smallest three CCGs are part of the Berkshire West CCG federation, along with Wokingham CCG. Darlington CCG said its “operating strategy” was that it “buys the majority of operational support it needs from its commissioning support service”, as did Hartlepool. North Lincolnshire CCG said it had previously relied on “a significant amount of commissioning support”, but this was being reviewed amid the closure of Yorkshire and the Humber CSU, which “will increase the overall CCG headcount to about 35”.
Despite the very small CCGs, the trend in 2014-15 was a large increase in total average CCG headcount, up 19 per cent from 2013-14. Employee costs rose 34 per cent on the previous year. This was largely due to CCGs coming into existence with many posts empty or not yet created in April 2013 - artificially supressing headcounts in 2013-14, several senior commissioners said.
Commissioners also said many CCGs had decided to add new posts during 2014-15 and to bring in house some services previously bought from support units. This appears to be reflected in a reduced CSU total headcount, although that could also be explained in part by CSU cost cutting efforts. There remained a strong need for cost cutting across commissioners in 2014-15 and 2015-16 as nationally set administration cost allowances were cut each year.
Two things could see CCGs continue to increase staff. Many CCG leaders still want to bring some functions in house; and many are taking on extra responsibility from NHS England via co-commissioning. On the other hand, groups still need to cut costs, and NHS England is leaning on some very big CCGs to outsource. In addition, groups might decide to pass functions over to providers (as proposed by Northumberland under the accountable care organisation model); to share more with local authorities; and/or to pass responsibilities to sub-regional bodies as may happen through Greater Manchester’s devolution plans.
More than four-fifths of CCGs have more non-GPs on their governing bodies than GPs
- Fewer than a fifth of CCGs have a GP majority on their governing body
- Often CCGs have other committees or groups with more GPs and other clinicians
- There may be further reduction of GP involvement in governance and management as CCGs move into commissioning primary care, work more closely with local government, and as leading GPs concentrate on provider side reform
Analysis of CCG board membership, according to 2014-15 annual reports, indicates fewer than a fifth of groups have more GPs on their governing body than non-GPs. Conversely, more than four-fifths have a non-GP majority. The average proportion of GPs on CCG governing bodies, according to the analysis, is 41 per cent.
HSJ does not have previous figures for direct comparison but reports in the past have suggested more than a fifth of CCGs have GP majorities. The low number is surprising given CCGs are intended to be led by GP practices.
The five CCGs with the lowest proportion of GPs on their governing body
|CCG||Governing body members listed||Members who are GPs||Proportion of listed members who are GPs|
|North Tyneside CCG||14||2||14.3%|
|South West Lincolnshire CCG||14||2||14.3%|
|Wyre Forest CCG||17||3||17.6%|
Under the Health Act 2012, and under CCG constitutions, they are controlled by their member practices. However, several have chosen to have more representation of managers, lay members, public health or other local authority stakeholders, or non-GP clinicians, at the expense of GPs, on the governing body.
Many groups have committees other than the governing body which have power under their constitution and are dominated by GPs. This variation in governance arrangements is another sign of the diversity in how CCGs are run.
South West Lincolnshire CCG highlighted the risks of conflict of interest for GPs running the CCG as a reason for reducing representation on its governing body. It said it also had a members' council with each practice represented and an executive committee, which carries out clinical redesign, and has a majority of clinicians.
North Tyneside CCG said its clinical executive team was “responsible for the day to day running of the CCG, and its membership includes four GPs and two nurses”.
CCGs’ growing role in commissioning primary care, and the imperative to work more closely with local authorities, could see them further reduce representation of GPs in governance and decision making roles. Many will endeavour to make these changes while protecting progress they feel they have made in making GPs feel involved in decision making. The national trend towards establishing bigger primary care providers and networks may create openings for GPs to take on senior provider side leaderships roles.