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

Kiss goodbye to CCG autonomy

Clinical commissioning groups can kiss goodbye to their autonomy, if it involves seeking to block service changes put forward by sustainability and transformation plans (STPs). That is the message from the interview with Simon Stevens we published this week.

National leaders are desperate to see the STPs biting the bullet on difficult service reconfiguration – closures and centralisations which will upset populations and staff, and have been put off for years. They’d also like STPs to clarify power and leadership across health economies.

Mr Stevens and his counterpart down the road at NHS Improvement have been getting out to meet STP leaders, who in some cases are asking them: “You say you want us to make these unpopular closures or centralisations – do you really mean we should get on with it? And how can we stop trust X or CCG Y from blocking it, since they and their residents will clearly feel they are losing out?”

This is indisputably an issue: Just last week this newsletter highlighted a case in the West Midlands, where Shropshire CCG’s governing body has vetoed a proposal backed by neighbouring Telford CCG, even though the two groups share a chief officer.

In the south Midlands, recent attempts to rationalise between Bedford and Milton Keynes hospitals have been hampered by the fact they are represented by two different CCGs each seeking to protect their local services. 

The message coming from Mr Stevens is pretty stark: if there isn’t agreement across a patch on a big reconfiguration then the STP leader’s decision (assuming he has confidence in them) will be final – and national officials will do whatever is needed to make it so.

How he will achieve that is not absolutely clear, but there are plenty of precedents for sheer national force in the NHS defeating local opposition.

One possible mechanism is creating the “NHS equivalent of combined authorities” to push region-wide change. This is floated and backed by Mr Stevens in what is a surprising intervention from a man wary about encouraging organisational navel-gazing. The term is a reference to the method which neighbouring councils have been using to pool some powers and functions.

The NHS England chief exec stresses this won’t be right everywhere, and indeed few of the STP leaders I’ve spoken to are rushing towards this type of arrangement. However, there will be a fairly widespread need to find a formal way to take STPs forward after June.

Where might the first ones surface? To simplify crudely, it seems the most likely cases fall into two categories:

  • The first is as a voluntary means of bringing together a system, helping to get governance and incentives right for making change and integrating services across mostly quite large health economy patches. Often this might be where the leader of a strong provider is the STP lead and is seeking to create a coherent system around it. Mr Stevens gives the example of the Royal Free (it is notable that the relationship between the north London foundation trust and its neighbour, University College London Hospitals, is still up for debate). Another might be Frimley Park, which an STP has formed around with the apparent support of CCGs; or University Hospitals of Morecambe Bay, which is not an STP-on-its-own but whose CCGs are again rallying around it under “accountable care system” proposals. Indeed, under this model, the idea of a combined authority bears a striking resemblance to the ACS concept. HSJ’s integration correspondent David Williams has spotted the appeal of this mechanism and written about proposals in Berkshire.
  • The second is as a means of forcing decision making, typically on service change, that needs to be done across a wider area. This could be more involuntary for some members, with them either chivvied or forced into combined governance. It is most likely in patches with multiple CCGs or trusts, one or more of which seem to be blocking decisions on necessary major service change (and probably already have big finance or performance problems). This could apply to the examples I’ve given above (Shropshire and Beds/Milton Keynes/Luton), and quite a few others around the country where counties are subdivided into multiple CCGs.

Is the “NHS equivalent of combined authorities” about joining with local authorities, or about devolution? Not necessarily – it is more about pooling within the NHS. However, Mr Stevens will have been well aware that the language used will bring local government to mind and get attention in that sector. During the interview he also heaped praise on those senior figures from councils helping shape STPs, particularly their approach to thinking about savings, based on experience of steep cuts. So Mr Stevens, the political operator, does currently seem to be smooth talking local government.

A final outstanding question is whether legislation is necessary, or useful, to bring about “combined authorities”. There are existing means of sharing governance which are being explored/implemented in some areas, including those discussed above, and national leaders still seem to think they can make a “whole system” financial control total work under current rules. But these approaches, as those trying to use them will tell you, are complex and very limited. Legislation was passed this year allowing NHS powers to be shifted to help bring about “devolution” projects – could this be used for internal NHS sharing?

Legislation was introduced to create local government combined authorities, and in a blog yesterday King’s Fund chief executive Chris Ham indicated he thought new law may be needed to bring the approach to the NHS.

This week’s: CCG chair tells it straight

Vale Royal CCG is grappling with really tough decisions about investment and savings – support an acute trust as encouraged from above, despite the consequences elsewhere? Chair Jon Griffiths addresses the dilemma head on in a blog this week.

He writes: “We cannot agree our plans with NHS England. We are forecasting that we will end this current financial year with a significant financial deficit. NHS England find this unacceptable. So do I, as a matter of fact, but I cannot see where the money can sensibly be taken out other than from the local hospital (see my first point above).” 

Dave West, senior bureau chief

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