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Cutting through the London fog

On Tuesday, ministers – and Simon Stevens – announced five devolution “pilots” to be tested in London over the coming year.

What that means is that, although there is significant impetus from chancellor George Osborne and Mayor of London Boris Johnson, there will not be any actual devolution of powers, functions or assets to the capital until at least 2017.

Although details are thin, not all the pilots appear to need any devolved power anyway. Plans to set up a health and social care accountable care organisation for three boroughs in north east London, for example, follow closely on the heels of work being pioneered through the new care models vanguard.

Among the most interesting proposals are those in north central London to explore how to make better use of the health and social care estate, unlocking value in surplus assets to invest in new models of care. Land sales could also free up land for much needed housing in the city. However, the initiative is so far led by commissioners. Local trusts and NHS Property Services, who between them own most of the local NHS assets, have not yet signed up.

A policy document also says any firm plans would be subject to “careful consideration” by the government and national bodies before they were approved, and that London’s CCGs and councils have committed to supporting national policy objectives.

The rise of the shell CCG

Obsessing about structure? We’re guilty, having asked clinical commissioning group leaders whether they believe the unofficial ban on mergers of CCGs should be lifted in our latest barometer survey.

Nearly six in 10 said yes. The unavoidable fact is many within CCGs, and elsewhere in the health service, believe such change is needed.

This pressure will only increase as admin budgets are cut further and experimentation with different models for commissioning gathers pace. Our barometer found the most popular avenue of exploration locally is to hand responsibility to accountable providers, with 60 per cent of respondents expecting to do this within 18 months. This was more than the amount who thought they would end up sharing with local authorities via devolution or other means.

However - for now - no removal of the merger “ban” is anticipated, and health systems stretching at their organisational seams are left looking for other options.

Hence, 59 per cent of respondents see themselves sharing more responsibilities and budgets across a group of CCGs. Examples of such clustering can be seen in London, where sub-regional commissioning “sectors” are increasingly important and form the basis of two of the “devolution” pilots announced on Tuesday, and elsewhere.

Such a trend, along with existing CCGs relinquishing responsibilities to accountable providers, will see an increase in the number of groups which, while retaining statutory accountability and governance, do a minimum of tasks for themselves.

These shell CCGs, with most functions delegated or outsourced and barely any staff, will be increasingly common and part of achieving commissioning reform with minimal structural upheaval.