Essential insight into NHS matters in the North West of England, with a particular focus on the devolution project in Greater Manchester. By Lawrence Dunhill

Smelling blood

It has been a bruising few weeks for Liverpool Clinical Commissioning Group, following an embarrassing investigation into its pay structure and governance processes.

However justified its remuneration levels were, NHS leaders awarding themselves “significantly higher” pay levels than their peers without following the correct procedures does not look good.

Both the chair and vice chair have now stepped down, and the remaining governing body members have a job on their hands to regain the confidence of some local partners.

It seems some of the city’s GPs (where there was already some resentment over the handling of quality incentive payments) are smelling blood, and may try to stick the knife in.

One doctor publicly called for a motion of no confidence in the CCG’s governing body last week, and the local medical committee will consider this formally at its next meeting.

With 92 practices in the city, there will be a wide breadth of opinion, but the public discord it creates is another headache the CCG could do without.

Vertical discontent

Another source of GP discontent is the ongoing uncertainty around Liverpool’s community services, following the calamitous collapse of the planned takeover by Bridgewater Community Healthcare Foundation Trust (in partnership with the council and GP federation).

The bungling NHS Improvement suddenly pulled the plug on the takeover after Bridgewater’s less than satisfactory inspection report. While the services are still being delivered by the vestiges of Liverpool Community Health Trust, which is to be disbanded, they are being managed on an interim basis by Alder Hey Children’s Foundation Trust and the city’s acute trusts.

This is where the next wave of problems start – because while the city’s GPs were comfortable with “horizontal integration” between primary care and community services, they don’t like the sound of “vertical integration” with the acute hospitals.

They argue that acute leaders have less understanding of patient needs in community settings, and are probably wary of being enveloped by a dominant acute sector.

Feelings are running so high that the GP federation felt the need to publicly raise these concerns at Liverpool CCG’s annual general meeting last week, while staff within the existing LCHT community services seem to share their reservations.

Without the broad support of primary care, which has already started working closer with community teams, the future management of community services is doomed to fail. The CCG must do all it can to broker productive discussions.

The option no one wants

The CCG says it wants all the NHS providers – including Mersey Care FT, which lost to Bridgewater in the original bidding process – to be part of those talks, but ultimately one of the trusts will need to be the lead provider and take overall responsibility.

Mersey Care could yet be the answer, but this may require the CCG to significantly increase the recurrent funding offered from the original £77m.

Alder Hey, which already delivers some children’s community services, might also be an acceptable option for the GPs, but the children’s FT might also insist on more money.

The ideal scenario would be for all the trusts and the GP federation to agree on the best organisation to host the services, avoiding a competitive process.

But without this, NHS Improvement, which must formally take the decision, may decide that the only option is to put the services out to tender. This would raise the possible scenario that almost no one in the city wants – a private provider coming in.

Major progress has already been made to improve patient outcomes and transform services in Liverpool in recent years, but there is a risk some of this good work will unravel. If the CCG’s leaders can help the system find the right consensus over the coming months, you might just conclude they are well worth the money.

Forecasting rollercoaster

The financial forecasters at Royal Liverpool and Broadgreen Hospitals Trust had an exciting 2016-17.

In its board report of 31 January, the trust said a “detailed review” of its year-end forecast had suggested a “likely deficit” of £4.2m. But days later the trust said the forecast was back on track to meet the £15.9m surplus control total – due to a significant increase in expected income from commissioners and extra incentive payments.

But then the trust’s month 12 board report said its financial data was unavailable, which suggested not all had gone to plan. This was confirmed by NHS Improvement’s year-end performance report for the sector, which said the trust finished the year with a £1.3m surplus.

In the bag

The Competition and Markets Authority is still formally considering whether to allow the planned merger of Manchester’s two big teaching trusts, but local leaders appear confident it’s in the bag.

So much so that an interim board has been formed between the two trusts, with the newly merged trust expected to be established in October this year.

In case there was any doubt over which trust was the senior partner in this transaction, bosses at Central Manchester University Hospitals FT are in the lead roles with the chair and chief executive of University Hospital of South Manchester FT in the deputy positions.

The group model

Another interesting development is the recruitment of two “hospital chief executives” for Manchester Royal Infirmary and Manchester Children’s Hospital, who will report to the new “trust’s group chief executive”.

This looks like the leadership structure across Salford Royal FT and Pennine Acute Hospitals Trust, which has a dedicated leadership team for each site.

With the merger, Manchester has taken a different approach to Salford’s “group” model but the job ad suggests the two aren’t so different after all.

North by North West takes an in-depth fortnightly look at one of the NHS’s most challenged and innovative regions. There will be a particular focus on the devolution experiment in Greater Manchester, but my scope will also include Merseyside, Lancashire, Cheshire and Cumbria.

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