Essential insight into England’s biggest health economy, by Ben Clover

Four or five?

Governance! Boring word, in practice quite important, covering as it does, who is actually in charge of stuff.

And in the confusing world of clinical commissioning group governance, change is coming - and quite fast in London.

The capital organised its commissioning structures into five areas back in the primary care trust era: south east London, south west, north west, north east and north central.

PCT clusters on these lines - merged up from about 30 PCTs in the capital - were an attempt to save on running costs by having an overarching management structure in these five areas, and centralise control. In terms of actually moving shared management, it worked better in some areas than others.

They did work fairly well in establishing local bailouts for under-capitated neighbour PCTs (something that is becoming controversial now people have started noticing it starting up again many years later).

It was also controversial that then NHS London boss Dame Ruth Carnall pushed clustering through a year earlier than the rest of the country attempted, but perhaps that move established the principle sufficiently that CCGs are now working in roughly the same patches as sustainability and transformation partnerships.

Everyone is supposed to be part of an integrated care system by April 2021, with the hope centrally that most will be covered by only one CCG.

But London is seeking to push ahead with merging all its 32 CCGs into five, with a target of April 2020.

This will be a challenge.

There are some questions this has thrown up already, one of which is about the number of CCGs.

There has been talk of having just four areas in the capital rather than five. This would mean effectively losing north central London as a designation.

This has some implications for what ends up where, financially.

Camden and Barnet in the north west, Islington, Enfield and Haringey in the north east?

This shouldn’t be too draining for NEL, as Islington’s relative over-funding broadly covers Enfield and Haringey’s under-capitation (see attached spreadsheet).

Camden and Barnet are both over-capitated, especially Camden, so if London does become four STPs/ICSs - with but one CCG in each and some underpowered local committees - NWL might be able to shift some of that money over and hope the local authorities don’t notice.

South of the river, the situation will get a bit weird with south west London and Croydon.

The one CCG-to-rule-them-all is already regarded with some suspicion in parts of SWL, with staff wary of job losses and the accidental loss of carefully crafted integration projects with local councils.

But Croydon had already announced it planned to go further than anyone else and appoint a joint CCG chief officer who is also chief executive of the integrated care provider trust.

SWL now say this job will be the much-less-exciting chief executive of the integrated care trust and the “Croydon place-based leader for the SWL CCG” - effectively a local managing director for the CCG, probably.

Although the CCG merger is not a done deal in SWL (applications will go in by the end of September if they do go ahead) the aim is for each “place-based leader” - ie person working on the existing CCG patches - to control around 80 per cent of the budget. The negotiations over exactly who will control what is going on now and I am sure will work fine until a difficult decision has to be made.

Down from the Guy’s tower

I don’t think you can blame Amanda Pritchard for wanting to retain her job as head of England’s most successful foundation trust.

Guy’s and St Thomas’ FT is one of the few that can take its pick of the best staff and for whom recruitment is not a terrible problem.

The job she will be taking up as national chief operating officer for NHS Improvement and NHS England is one everyone knows has been difficult to recruit to.

Who would want to answer to one chief executive and two chairs - before you even get to the involvement of ministers - while being responsible for a provider sector that is underwater financially, struggling in the face of demand and has intractable workforce shortages?

The roles being taken on by the chief operating officer (which is poorly named if you’re trying to attract people who are currently chief executives) are ones in which previous incumbents have struggled. Two of them, Matthew Swindells and Ian Dalton, had to leave unhappily. Their predecessor Sir Jim Mackey got to leave and go back to his successful FT in the north east – Why wouldn’t Ms Pritchard want to do the same?