What NHS England isn’t telling you, and more indispensable weekly insight for commissioners, by Dave West
The new planning guidance stays true to Simon Stevens’ mantra on organisational structure – there has never been and will not be a single right way to organise things.
The 44 STPs were a very top-down imposition, but they should be seen as incubators of the future health service, not a permanent imprint of what it will become.
This means the uncertainty in the system (destabilising and painful) will persist, but it is surely right and preferable to the alternative cookie cutter approach.
Some will have argued, for example, for an attempt to replicate widely the appealing clarity of Frimley Health’s STP-cum-PACS model. That would not work.
And in a welcome step back from the centre’s earlier hard line on the 44, the 2017-19 planning guidance signals that some of the current footprints could be allowed to split, taking on system control totals and new leadership arrangements on smaller patches.
There won’t be a wave of STPs taking up this option, though. Those most likely to do so are those with very large and not very functional footprints – they might not have been created if some people had listened to sense at the time. In this category are West Yorkshire (2.5 million population) and Cheshire and Merseyside (2.4 million). Coast, Humber and Vale is another awkward patch though its population is not so big at 1.4 million.
The other category of potential STP uncouplings are where, though the existing footprints are not so bad, constituent parts can make a good case that they would be an effective, very cohesive health system on their own.
Those approving bids to change an STP footprint will be looking at what will replace it: is there a potential Frimley-style extended PACS within it; a city region; a large local authority willing to lead; or a group of clinical commissioning groups that will join or merge? Changes will often be complicated by parts of the patch which aren’t part of any of the above – can they comfortably link to a next door STP or would they be cut off?
While simply tolerant of STP splits, the planning guidance is positively encouraging about CCGs coming together to share senior leadership, decision making, contracting and other management. The option of merging altogether is firmly back on the table too.
Sharing chief officers and finance officers is already common and is spreading quickly. By my estimation a quarter of CCGs have a shared chief officer. Twenty-two people run more than one group, spread across 52 commissioning groups. There are roughly 179 chief officers, including these 22, covering England.
Momentum is growing and the signal in the planning guidance will accelerate it further.
North Central London is a particularly high profile patch (housing David Sloman’s Royal Free “hospital chain” and UCLH’s proud academic centre) now considering joint leadership and other options, but far from the only one.
In a year’s time, the number of chief officers could easily be cut by a third or a half – with big implications for what it means to be a CCG leader, aside from anything else.
There will also be more CCGs sharing decision making and contracting, in the interests of whole health economy consistency; and greater sharing of lower level management across groups to squeeze running costs even tighter (spelling further problem for commissioning support units).
Plenty of CCGs are taking these steps more or less voluntarily, while NHS England is pushing some others with its interventions.
How many full CCG mergers should we expect?
Several areas are officially considering or proposing it (Manchester, Birmingham, Bristol and Buckinghamshire); this has moved a long way in just a few months. But plans may be in the early stages and none have official sign-off yet.
NHS England has been clear that it is still wary about the distraction of CCG mergers, and will still apply approval tests including on the impact on clinical engagement. We don’t know yet how high the bar will be.
My best guess is there will be few if any CCG mergers in time for 2017-18 but a flurry for 2018-19.
The Commissioner’s reading list
- Patricia Hewitt on her time at the Department of Health and elsewhere in government – interview for the Institute for Government
- Richard Murray on the planning guidance for the King’s Fund – including on central control and organisational targets
- The planning guidance gets perilously close to being useful – Rob Findlay on the new approach to operational planning
Dave West, senior bureau chief