The Commissioner: More good CCGs will merge than bad ones

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

Merger: not just for bad CCGs

The message is going out from NHS England, unofficially but with little disguise, that its moratorium on clinical commissioning group mergers is being lifted.

Talk of merging CCGs often focuses on failure: generalisations that CCGs are too small and must all be consolidated, and/or the assertion that sub-standard CCGs could be forcibly merged. The sense of failure around commissioning will only grow stronger if NHS England goes ahead with the logic of its assessment framework and labels many groups as “inadequate” in coming weeks.

And it’s true NHS England is slowly gearing up to get tough with the CCGs in severe trouble, including by pressing them into merger. But given some of these are already among our biggest (NEW Devon, Bedfordshire), it is not universally applicable even for these.

This brings me to a first observation of four about how the current commissioning restructure will most likely take shape: It won’t be all about merger, it will also be about the role of councils, accountable providers, devo, more flexible joint working; and about further watering down the fixed role of GPs and GP membership in local commissioning.

The second is that it won’t and shouldn’t be all about failing CCGs.

Plenty of CCGs that are doing a good job are feeling strait-jacketed by their current configuration. They are often painfully aware that their set up is not right for the task in front of them, as HSJ’s editor recently observed. These aren’t on the naughty step or expecting to be rated inadequate in forthcoming CCG ratings, but are alert enough to see they need to change. Today we report on plans in Buckinghamshire - there are plenty of others thinking in the same way. More decent CCGs will merge than terrible ones.

I’ll write more soon about which areas may be at the front of the queue for merger, but we’re likely to be looking at CCGs smaller than their top-tier council, which could merge to become coterminous with it; those which are pretty small and may be struggling to manage financial stability running costs, or other challenges; and/or those wishing to expand across an aspiring city region or devolution area.

A third observation is that CCG mergers across an entire STP patch will be the exception not the rule. There will be some - Birmingham’s plans are a good example, and STP work will certainly encourage and hasten consolidation.

But some would like to think of the map of 44 STP footprints as a guide to the future shape of commissioning, anticipating or hoping for a move to much larger areas. I think in most cases STPs will be an incubator of future commissioning models, not necessarily foreshadow them. Most STPs are too big for this – not many mergers on this scale will come organically, at least for the next few years. At the other end of the spectrum, it’s often forgotten in the centre that six STPs already have only one, large, CCG member covering the whole health economy (North Cumbria, Cambridgeshire and Peterborough, Dorset, Kernow, Gloucestershire and Somerset).

My final observation – although it should be obvious from the above – is that the shift by NHS England to allow mergers does not spell a quick resolution to the massive uncertainty about commissioning. The shape of commissioning will be very fluid for a few years, constantly subject to potential change – more like much of NHS provision, or many non-statutory sectors, than a sector with the fixed tasks and boundaries that some expect. This means individuals and organisations that want to preserve their own role, or reshape if for themselves, will have to work hard at it and win arguments.

Senior commissioning leaders are invited to our Commissioning Summit event in September - a high level forum for debating how commissioning should develop, delivering STPs, and the financial climate. Confirmed contributors include Simon Stevens, Alistair Burt, and NHS England’s new director for commissioning operations and informatics, Matthew Swindells. Get in touch via the website.

The Commissioner’s reading list

This will be a weekly pick from the barrage of publications, articles, videos and tweets which may interest commissioners.

In video from last week’s NHS Confed conference: Simon Stevens’ Q&A is worth a watch. He talked about the coming financial “reset” intervention and (at about 40 minutes) dropped some hints about his more flexible approach to CCG merger. NHS Improvement’s Jim Mackey, though he’s not generally commissioners’ best friend at the moment, gave a very robust and honest call to action speech. Blackpool CCG’s chief clinical officer Amanda Doyle had a brilliant analogy for leading an STP; and Aylesbury Vale’s chair Graham Jackson gave reflections from a CCG perspective.
Our editor’s recent leader column - titled Many CCGs are not fit for purpose and must be re-organised - was a timely contribution to the CCG merger debate, as was referenced by Simon Stevens on stage at the Confed conference. Graham Jackson, for NHS Clinical Commissioners, has responded.
Sheffield public health director Greg Fell has been writing some good quick-fire blogs about prevention in STPs, as well as primary care, future public health approaches, and more.