The merger of CCGs has been contested locally in many areas, primarily because the loss of more local CCGs further limits the extent to which NHS management can be held accountable or pressed to respond to the health needs of specific communities.
Critics argue that the strategic objective of creating Integrated Care Systems also brings with it the threat of remote, unaccountable bodies, each tied to rigid cash limits (“control totals”) and led not by local needs but by private management consultants.
Merged CCGs covering vast geographical areas – and in some cases in excess of 2 million population – are unlikely to be more responsive to local pressure. Eliminating CCGs also cuts the links with many local council scrutiny committees.
The Long Term Plan which demanded the mergers was sidelined for four months this year by the Covid-19 pandemic. On 17 March, before lockdown, NHS England Chief Executive Simon Stevens spelled out a series of new priority actions to be implemented by every trust and CCG, and declared that NHS England was: “Deferring publication of the NHS Long Term Plan Implementation Framework to the Autumn, and recommending you do the same for your local plans.”
However that deferral came to an abrupt halt on July 31 with a letter from Stevens and NHS Chief Operating Officer Amanda Pritchard headed: “Important – for action – Third Phase of NHS response to Covid-19.”
The letter gave trusts just the month of August to draw up and implement delivery plans, to run from September 1, to “restore full operation of cancer services,” and rapidly resume normal levels of service for elective care.
But the letter also made clear that while working flat out to get services back up and running, NHS bosses in some areas that had not already done so were also expected to force through CCG mergers to create the basis for “Integrated Care Systems”:
“As we move towards comprehensive ICS coverage by April 2021, all ICSs and STPs should embed and accelerate this joint working through a development plan, agreed with their NHSE/I regional director, that includes … Plans to streamline commissioning through a single ICS/STP approach. This will typically lead to a single CCG across the system. Formal written applications to merge CCGs on 1 April 2021 needed to give effect to this expectation should be submitted by 30 September 2020.”
This has not gone down well in many areas, where councillors and campaigners have agreed that no clear case has been put forward showing any advantages of merging into larger, more distant organisations. Indeed the positive examples of what merged CCGs (and ‘Integrated Care’) could achieve are all a confirmation that the NHS could already be working better – if it were not for the fragmentation and bureaucracy imposed by Andrew Lansley’s 2012 Health & Social Care Act.
On 18 Sept the HSJ reported NHS England’s intervention to reject plans for two merged CCGs rather than one to span Cheshire and Merseyside, and noted that: “Other large systems such as North East and Cumbria, Greater Manchester and South Yorkshire and Bassetlaw have also been looking to retain more than one CCG. … It is unclear what would happen if the move for a single CCG is heavily opposed by practices and councils.”
Indeed guidance on mergers from NHS Clinical Commissioners and the Local Government Association makes clear that: “What this looks like in each local area may vary, with some areas having more than one CCG per ICS, while others will include more than one local authority. “
It also notes that: “Engagement between CCGs and local government is not just important, it is also a legal requirement. All CCGs that are applying to merge must show that “they have effectively consulted with the relevant local authority(ies) regarding the proposed merger” and have a record of the feedback they receive.”
The legislation and regulations covering CCG mergers (which requires dissolution of the merging bodies) also state that:
- there must be an assessment of the likely impact of the dissolution on the persons for whom the CCG to be dissolved has responsibility
- Each dissolving CCG must also “seek and take into account the views of unitary local authorities, other CCGs affected by the dissolution, and individuals to whom any relevant health services are being or may be provided.”
Who will now blink first in the stand-off: local authorities or NHS England?
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