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

CCG no evil

The life expectancy of many clinical commissioning groups is shortening rapidly as we start to get a clearer view of how NHS commissioning is going to work in future.

The clearest view that I’ve seen yet came from Greater Manchester over the summer, where the region’s devolution team accepted key recommendations made in a review by Deloitte.

The key suggestions are not a major surprise as they follow the sort of thinking (and some action) that’s happened over the last year, but it still feels significant to see this set out in detail.

These don’t just look like short lived plans either, as transformation funding will be conditional on delivery of the recommendations within two years.

First, the region’s CCGs must effectively merge with their local authority to create a “strategic commissioning function”, which would require fewer staff than are currently employed.

These SCFs (Strategic Commissioning Functions – let’s hope they can come up with a better name/acronym) would be supported by a Greater Manchester commissioner for these functions. The GM commissioner would also take care of specialised commissioning and regional services like 111 and ambulances.

But the “tactical” commissioning responsibilities (and staff) of CCGs and councils would transfer to community or acute providers, such as the local care organisation being created in the city of Manchester, or the hospital group led by Sir David Dalton.

CCGs will continue to exist as legal entities, of course, until new legislation can be passed. But their effective powers will be channelled into the SCFs, which in some cases, depending on the personnel, will probably start to feel more like a department of the local authority.

Although all this will sound relatively easy for boroughs that have already implemented some of the changes, such as Manchester, Salford and Tameside, it will feel a long way off for others, such as Rochdale, Bury and Trafford.

The review did not offer a clear solution to the bugbear of some providers, which is that they need to deal with too many different commissioners with differing priorities and methods. The Deloitte report acknowledges this problem, and points out the potential benefits of acute services such as maternity, electives and outpatients being commissioned at a GM level. But it also warns of the downsides such as fragmented pathways cutting across acute and community settings.

Tellingly, the report concludes that “further work and engagement is suggested to gain system-wide agreement”.

Tax issues

There is no doubt that major progress has been made to create a single out-of-hospital provider for Manchester, but it’s looking like the ambition for a distinct and jointly owned community provider by April 2018 will not be realised.

Potential VAT liabilities under current legislation mean a joint venture company is likely to be ruled out in the short term, and “interim” governance arrangements are instead being put in place for next year, or until there are legislative changes.

This is likely to involve the “local care organisation” being hosted by the new mega trust being created between Central Manchester University Hospitals and University Hospital of South Manchester, as they already provide community services.

Those leading the project say they are prioritising the design of frontline services rather than getting bogged down in the organisational structures, but will be conscious of potential problems in the long term.

One of these issues goes back to local care organisations taking over some of those “tactical” commissioning roles from CCGs, which (again pending new legislation) would include delegated responsibility for primary medical services. Because there is a risk here that if the LCO project is seen to be driven by the acute sector, it will struggle to retain support from GPs.

So until there can be genuine joint ownership of the LCO between the various providers, including the mental health trust, local authority and GP federations, efforts will be made to create a sense of independence for the organisation. But having a big hitter from the non-acute sector, Michael McCourt, in line to lead it should help.

Awkward looking

Mr McCourt’s old job as chief executive of Pennine Care Foundation Trust has now been filled by Claire Molloy, who started in the post this month after her move from Cumbria.

Just before Mr McCourt’s departure, Pennine lost out in its bid to take over Manchester Mental Health and Social Care Trust, and provides what now looks a potentially awkward set of community and mental health services.

The trust delivers community services across Bury, Rochdale, Oldham and Trafford, but these may need to be split between the distinct LCOs emerging in those boroughs.

Meanwhile, some may push for a further consolidation of mental health services and for the trust to be merged into the new Greater Manchester Mental Health FT (created through Greater Manchester West’s acquisition of MMHSCT).

It will be interesting to see how Ms Molloy envisions the trust’s future and strategic direction, and whether it wins support.

More bloodletting in A&E?

Several NHS hospitals in the North West will be very anxious about accident and emergency performance after the resignations of two trust chief executives in London and Kent following pressure from the centre.

Pennine Acute, East Lancashire, Bolton, Wirral and Aintree have consistently struggled to meet the four-hour target and are among the worst performers on the standard in 2017-18.

Widely respected leaders such as Jackie Bene and Kevin McGee are clearly not going to get the boot, but will still feel significant pressure going into winter.

All you need is labs

We can expect there to be some pretty disgruntled consultants once news filters through of NHS Improvement’s pathology networks.

The proposed “hub” sites in the North West are Lancashire Teaching Hospitals, Central Manchester University Hospitals, Pennine Acute Hospitals, and Royal Liverpool and Broadgreen University Hospitals, which means all the rest will be “spoke” sites.

Many clinicians (and managers) see a fully fledged pathology lab as a status symbol, and if tests have to be sent down the motorway to a neighbouring trust this will inevitably be interpreted as downgrade in status and reputation.

Don’t be surprised if we see the proposals being challenged by trusts such as East Lancashire, which has previously fought hard to retain its laboratory.

Two heads better than one?

The population of CCG chief officers is dropping even faster than the number of CCGs, with joint leadership roles now firmly in vogue and providing a stepping stone to mergers.

It was announced in August that Chris Clayton would take over as joint accountable officer of four CCGs in Derbyshire, and I think it’s unlikely that we’ll see a like-for-like replacement at Blackburn with Darwen CCG (his current employer). I reckon Mark Youlton, his counterpart at neighbouring East Lancashire, will instead be named joint accountable officer of both CCGs.

As with Greater Manchester, the longer term vision for strategic commissioning in Lancashire is for consolidation at county level, with providers taking on tactical commissioning functions.

Top marks for PFIs

It’s not often that you read a positive story about the private finance initiative, but here’s one from St Helen’s and Knowsley Teaching Hospitals Trust.

The trust was ranked as the best acute provider in England in the national PLACE assessments, which gave top marks to both its PFI hospital across several measures, including cleanliness and the condition of its buildings.

Whether the hospitals are worth the annual unitary payment (£49m in 2017-18), for which the trust requires ongoing support from the Department of Health, is perhaps another matter.

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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