What NHS England isn’t telling you, and more indispensable weekly insight for commissioners, by Dave West

So frenetic are the times that commissioners are operating in this summer, that there are five things to cover in this week’s newsletter – and Brexit is only fourth in line.

CCG ratings are still coming – and still a silly idea

The government last year instructed NHS England to publish headline ratings for clinical commissioning groups, in Jeremy Hunt’s favoured Ofsted-style categories, in June. You have probably clocked that it is now July and, while clinical commissioning groups have been given draft judgements, nothing has been finalised or made public.

The health secretary generously granted officials a delay to the June deadline. Unfortunately, though, these are still expected to arrive in one form or another during this month, along with additional ratings for several priority clinical areas.

Where has the process got to?

CCGs’ draft ratings have been calculated by local teams according to the assessment guidance. This has led to quite a lot of groups being rated “inadequate”, it is thought, with somewhere between few and zero judged as “outstanding”.

This seems to be partly driven by two technicalities: ratings are dictated by CCGs’ lowest score across several domains rather than an average; and widespread bad performance on targets and finances mean it’s impossible for most groups to do well. The wider problem is the absence of a clear definition of what the system is actually trying to rate and why. As the King’s Fund pointed out last year, creating meaningful CCG ratings would require a massive CQC-style infrastructure. No one is going to do that, thank God. The whole idea is pretty pointless since everyone is agreed the system needs to measure whole systems not small parts of it.

Anyway, NHS England’s commissioning committee has agreed the delay to publication, and it falls to Simon Stevens and colleagues to decide whether they want to shuffle the goalposts to prevent swamping the commissioning sector with “inadequates” and/or create a few more examples of success at the top.

This will probably happen to some degree – but cynics suspect the centre wants to label groups as failing in order to speed up CCG mergers and other reorganisation.

This theory is lent weight by the clear signals from NHS England recently that it wants to step in at troubled groups, and by a message from Simon Stevens to NHS England staff on Monday, stating it would this month “publish our annual assessment of all 209 CCGs, linked to clear action to step in and support turnaround of those that are struggling, consistent with their STPs’ local strategic direction”.

Slaughtering management costs

Is there a momentum building behind another big swing of the axe at management and admin costs? I suspect it will hit at both national and local levels in the not too distant future. Jim Mackey has identified the need to cut transaction costs, seemingly with reference both to the national arm’s length bodies, and to local NHS organisations.

The current blurring of the purchaser and provider roles in the NHS helps make the case for collapsing NHS Improvement and NHS England (some would argue the CQC too) into one. The shared local director role which has been put in place between the two in the North East may be a way forward. Ian Dodge has pointedly highlighted that the coveted integrated care model in Alzira, Spain, has one regulator to deal with, not the three-plus the English NHS has to navigate. The new mood for CCG mergers could sit comfortably alongside slimming admin cost too. (All that said, as HSJ and others have consistently pointed out, NHS running costs are small by international standards, and shortages are already doing real damage in some spheres.)

One imbalance in the system that certainly needs fixing, although it’s not straightforward, is the large proportion of NHS management currently occupied in national rather than local organisations – this is surely part of the next phase.


If you haven’t clocked it, Jim Mackey’s letter to providers last week takes another step in central direction of cost reduction. This time they are asked to speed back office and pathology consolidation, and earmark elective services that can be quickly closed to save money – all by the end of July. Mr Mackey is making fast work of this commissioning business. Trusts will be looking up so much, they might forget how to look out.


The implications for the NHS, like much else, are pretty unpredictable. We have published analysis on this pernicious uncertainty, staffing concerns, the prospect of even greater public spending constraint, and political planning blight.

An outstanding question is how the Brexit fallout will affect those who had reconfiguration plans lined up to go this summer/autumn. The original sustainability and transformation plans deadline submission has just passed – many are not yet coherent plans, but some areas are bringing forward advanced proposals for major change. A key question is whether some of these will now slip – let me know, in confidence, what your experience is.

Meanwhile, speaking about Brexit at the Health + Care event, NHS Clinical Commissioners co-chair Graham Jackson also pointed out that the presumption there would be no wholesale NHS reorganisation until at least 2020, because the current government is strongly against it, no longer holds. There may be an early election, and in any case so much water will have passed under the political bridge that the no reorganisation dictum, linked to Cameron administrations, might no longer stand. Dr Jackson’s view was that there is no great need to worry about CCGs disappearing, but what is critical is protecting and preserving the clinical engagement that some groups have achieved.

I’m interested in any ideas readers have about how this might be achieved – what might it look like to novate the current modes of clinical involvement into a restructured NHS?

The STP deadline is passed, long live the STP deadline

As I have noted previously, NHS England decided the STP process was becoming more of a pipeline of approvals than a single deadline on 30 June, because many plans were not on course to be in a good state. We now seem to be moving to a backstop deadline in October, potentially tied into a reimagined annual planning process. Mr Stevens’ Monday letter said: “We’re working with NHSI on bringing forward the annual planning timetable for 2017-18, and potentially 2018-19 too – linking this to final STP submissions in October, with full local public engagement and consultation wherever needed.”

  • Senior commissioning leaders are invited to our Commissioning Summit event in September – a high level forum for debating how commissioning should develop, delivering STPs, and the financial climate. Confirmed contributors include Simon Stevens and NHS England’s new director for commissioning operations and informatics, Matthew Swindells. Get in touch via the website

The Commissioner’s reading list

A weekly pick from the barrage of publications, articles and tweets which may interest commissioners

Dave West, senior bureau chief

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