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

We have published the results of our latest CCG barometer survey this week – thanks to the 99 chairs and accountable officers who filled it in.

The news stories put in lights some key messages about STPs:

The results are a great source for following important developments and trends, and for taking comfort from the concerns and tribulations of others – you can download the full findings including the free text responses.

Here are three specific observations from the survey that I haven’t brought out in the coverage so far:

Finance squeeze hits commissioning

Only 49 per cent of respondents are expecting their CCG to end this financial year in cumulative balance or surplus. It’s difficult to read across from the survey, despite a large sample size, to real CCG outturn positions.

However, 49 per cent is substantially worse than the latest official NHS England forecast, which has 39 CCGs (20 per cent) planning a cumulative deficit. It resonates with anecdotal reports that the CCG position is getting very tight, and is a reminder about the substantial shift of the financial pain onto the commissioning side this year.

The great hope at the centre is for a big PR win from cutting the heavily reported provider deficit, whatever this takes (see: the sustainability fund). PR can be very important though, and a positive mood from that win could help persuade the government that the NHS is back in control and deserving of more funds.

Relationships problems, still

In some areas I have picked up in the past few months a real improvement in relationships and, for a few, a sense that they are pulling in the same direction for the system. However, plenty of the survey responses give the lie to the idea that sustainability and transformation plans have sorted relationship and organisational clash problems. Many cite age old issues not overcome by a system ethos. “Despite good working relationships across the board and an apparent commitment to transformation, there remain complex discussions ahead which revolve around organisational and political protectionism,” says one respondent.

Another says: “There has been longstanding good relationships in our footprint for decades. However, clarity over governance is still evolving and the conflict between current responsibilities as statutory bodies and system responsibilities is not yet settled. Essentially it is the club and country issue and a lot of providers are seeing this a club opportunity rather than a system requirement.”

Asked about barriers to STP success, 61 per cent cite organisational duties/priorities trumping whole system plans. NHS provider opposition to changes is named by 54 per cent.

John Rooke of PA Consulting Group, which supported the survey, picks up on this issue of shared understanding, in the context of the two-year planning process, in his comment piece.

This is in the context of the whole thrust of the two-year planning round being to try to force organisations to pull together as a system.

Commissioning development going slowly

We asked CCG leaders: “How is the nature of your collaborative commissioning relationships with other CCGs and local authorities changing?” There were majorities “taking an increased number of key commissioning decisions in partnership with others”; “considering sharing more functions (excluding leadership/governance) with other CCGs”; and “considering the development of pooled budgets with one or more of its corresponding local authorities”.

However, there was no overwhelming widespread expectation of more radical departures from the current CCG set up.

Forty-three per cent are considering shared leadership, for example a chief officer or finance officer, with other CCGs – a reasonable chunk but not, I think, the kind of outbreak some would like to see.

Only a quarter said their CCG was considering merging with another CCG: this is not significantly more than have said they are heading for merger (so far, it would seem, mistakenly) in previous CCG barometers over the past year or so.

Similarly, only 14 per cent expect “substantial commissioning functions [being] passed to a provider or providers” in the next 12-18 months. Only 16 per cent expect the PACS contract being introduced in at least one instance in the same period. A slightly more respectable 42 per cent envisage at least one MCP contract being introduced.

Some of this may be because, as HSJ has been observing, these kinds of widely desired structural changes are taking longer than some expected. So they may come more widely, but take longer than 18 months.

The Commissioner’s reading list

Dave West, senior bureau chief

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