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

The announcement of clinical commissioning groups’ ratings is due any day now. The health service will soon have its first “outstanding” and “inadequate” CCGs.

This newsletter explains the machinations of recent weeks, and what to expect next, although things are still subject to change at the whim of those making the decisions.

There’s quite a bit to say. This looks set to be an important moment for the commissioning system. 

Initial ratings scrapped

The initial process for deciding overall assurance ratings resulted in many, many groups being given “inadequate” as their draft ratings – somewhere in the region of three-quarters of them. Somewhere around zero were judged “outstanding”.

Officials at NHS England, as recently as the last few weeks, realised this was ridiculous, and recognised that the great unwashed might reasonably over-interpret a declaration that three-quarters of the country’s NHS is inadequate. It would not be a step to take lightly, or on the basis of a nonsense ratings system.

NHS England top bods therefore formally decided that the decision process was flawed and, as predicted in this newsletter before, tweaked the rules and ordered widespread re-rating to give a rosier, less absurd, picture.

Inadequates and intervention

Following this, there are now in the region of 20-30 CCGs rated inadequate and around a dozen outstanding.

The inadequate group – about one in eight CCGs – can be expected to get automatic intervention from NHS England, either via the imposition of legal directions or the informal “special measures” label.

Only eight CCGs are currently subject to legal directions so expanding this to more than 20 would be a big step-up of formal intervention.

More important, though, if things run as those at the top of NHS England hope (and that’s a big if), will be the big change in the form and type of interventions.

Time for mergers

Partly that is because of the lifting of NHS England’s ban on CCG mergers. NHS England will now, where it thinks merger will work – probably guided by an area’s STP leader - take steps to strongly encourage or even direct it.

There are quite a few patches where there is a good case that merging multiple relatively small CCGs, some or all of which have struggled, could create a bigger commissioner with a better chance of achieving what the health economy needs.

The reasons for merger vary from case to case, but they include: a better chance of negotiating with providers; consistency in commissioning messages; dissolving parochial concerns into a wider health economy interest; more financial wriggle room; ability to attract and keep good leaders and managers; surviving the management cost cap; a wider field to find clinical input to the CCG; and diluting conflict of interest problems.

In aggregate, the hope is that the new, bigger CCGs would make a go of grappling with a health economy’s often immense challenges where its smaller predecessors have sometimes woefully failed.

Alternatives to merger

While merger will be the most common organisational option for inadequate groups, it likely won’t be the only one (not least because some troubled CCGs are already very big – perhaps too big).

There will probably be an attempt to try to introduce a range of more exotic alternatives. Simon Stevens suggested more than a year ago that failing commissioning groups could see their responsibilities forcibly passed to other CCGs, councils or “integrated providers” under an accountable care type arrangement.

Another idea being considered is for STP leaders to take over as accountable officer of failing CCGs in their patch, creating shared senior leadership.

That would neatly help spread a consistent strategy, and would be pretty straightforward where the STP lead is chief officer of another CCG. If a trust chief executive STP leader were to take the reins of a CCG, though, this would be a major policy departure and it’s not clear whether rules allow it. (Nor is it clear whether NHS England can legally pass a CCG’s responsibilities to a council or a provider – some commissioning groups believe they can’t achieve this even when they want to.)

Financial ‘reset’

The national tough-guy act with CCGs will be linked rhetorically to the “reset moment”, which is poised to be announced, with a focus on recovering NHS finances. It will presumably come alongside a set of measures pressing all CCGs to contain costs, in the vein of what Jim Mackey has asked of providers – a mandatory acceleration of RightCare seems likely, at least.

There is an intention to send a message to both providers and commissioners: deliver the numbers now or you will be intervened upon.

However, it’s worth noting that intervening in CCGs, and/or getting them to merge, will make little difference to spending this year. Any benefit will come in the medium term from creating a better functioning structure.

Flaws in the plan

Although it may be announced this week with a flurry of misleading rhetoric about failing organisations and boards, there is a lot to be said for intervening to sort out the persistently failing commissioning structures in some areas.

But there are some big holes in the plan being put forward that need to be filled.

First, what is the plan for improving the “requires improvement” CCGs (likely to be the largest group), or the ”good” ones? NHS England has, for years, promised a plan and resources for improving CCG commissioning (as it was clear from day one that many would falter). There’s still very little to show for this.

Second, decisions and policy about the future shape of commissioning, and about CCG assurance, have been stuttering and sometimes shambolic. Those working in CCGs and NHS England are suffering from a lack of clarity and a steady flow of unexpected changes in direction from above. Few leaders in the sector feel they understand, or have control of, their future.

The long promised NHS England roadmap for commissioning seems itself to have got lost (latest eta: autumn). The legality and practicality of some of the options on the table is totally uncertain. Will the volley of ratings and new policies this week exacerbate these problems, or start to solve them?

  • 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

Dave West, senior bureau chief

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