The NHS is caught up in more top down change. In over 20 areas the local bodies responsible for paying and organising our healthcare – Clinical Commissioning Groups (CCGs) are involved in a series of mergers, to form entities that cover much wider areas. The reasons behind the change are already causing controversy, not least because the public are in many cases being kept out of the process.
The two drivers of the CCG mergers are financial and the development of integrated care systems (ICS). They amount to a major NHS re-structure just a few years after its biggest shake-up to date in 2012.
In November 2018, NHS England wrote to all CCGs telling them they needed to make 20% efficiency savings to their running costs, placing “administration limits” on each.
NHS England have suggested that they save money by “exploring mergers and joint ways of working” – share back office and other functions and aim for savings on administration and a greater spend on patient care. Casting doubt on the plan an HSJ analysis concluded that efficiency savings from mergers will not deliver the 20% reduction in running costs and in many situations may result in extra cuts.
Nationwide CCG mergers are designed to enable the government’s new direction for the NHS – which is based around the development of Integrated Care Systems across England, as outlined in the NHS long-term plan announced in January 2019.
The plan states that England should be covered by ICSs by April 2021, and that an ICS should have just one CCG acting as commissioner across its area.
To speed up the merger process NHS England will now approve mergers throughout the year rather than just once a year. The largest new CCG being planned will be formed by the merger of eight CCGs in North West London; this will cover 2.2 million people.
Political expediency plays a strong part in the merger plan as the government does not have a majority to get a new NHS reorganisation bill through Parliament.
Therefore, merging CCGs to the size of the bigger integrated Care Systems is a work-around solution to form a new structure out of the existing CCGs – who despite the emergence of ISCs will remain the body with the statutory responsibility for planning and funding local healthcare.
Why is it controversial?
Some commentators see this as u-turn away from the idea of local decision-making that was a strong theme within the 2012 NHS changes. They claim that forming super-CCGs will make health planning more remote from the populations they serve.
Local GPs who were cast as being in the driving seat of CCGs back in 2012 are now feeling distinctly left out, according to a Dr Richard Vautrey, chair of the BMA’s GP committee.
“We have heard from members who are extremely alarmed that mergers appear to be rapidly moving forward in their areas without clear approval from, or sufficient engagement with, local GPs,” he said.
Enforcing “tricky” decisions
One of the reasons behind mergers is to minimise any local voice or dissent while controversial closures and downgrades of hospitals and services are pushed through.
In Lancashire and South Cumbria, where 8 CCGs are planning a giant merger alongside the formation of an “integrated care sys-tem”, the director of finance and investment has openly stated to the Health Service Journal that: “The place we need to get to is where we can enforce decisions on a majority basis.” He wants to be able to push through “tricky” decisions that will be opposed locally.
Hospital “reconfiguration” is a key concern in Lancashire, with potential permanent loss of A&E and acute services in Chorley: eliminating any local voice will make that easier.
Threat to planning
In early 2019, the Public Accounts Committee (PAC), commenting on the move to commissioning of services by ICS across much larger areas, noted:
“There is a risk that CCGs will lose touch with the needs of their local populations as they commission services across larger populations. It is vital that CCGs, in whatever form, understand the needs of their local populations and have good links with local GPs. But as CCGs become responsible for commissioning services across larger populations there will be a tension between commissioning at a larger scale while maintaining an understanding of the health needs of local populations.”
A November 2018 report from the National Audit Office on CCGs also noted that the mergers seem to go against one of the original aims of the CCGs, that of commissioning services appropriate to the needs of patients in the local area:
“This larger scale is intended to help with planning, integrating services and consolidating CCGs’ leadership capability. However, there is a risk that commissioning across a larger population will make it more difficult for CCGs to design local health services that are responsive to patients’ needs, one of the original objectives of CCGs.”
The Public Accounts Committee has also identified a loss of accountability for patients:
“We are also concerned about how patients will understand who makes decisions and keeps a close eye on the local NHS finances.”
At present the performance of individual CCGs is assessed by NHS England; PAC was concerned that as the ICS develop, accountability systems will be weakened as NHS England moves to assessing entire ICS rather than individual CCGs.
“it is important not to lose sight of the need for robust accountability structures which make it clear who is ultimately responsible for planning and commissioning decisions.”
Existing flaws made worse
The accountability of commissioning and other key decisions has already come under sharp criticism and critics believe that these weaknesses will be exacerbated through mergers. A catalogue of contracts have collapsed after CCG led tendering processes and local critics have called for these decisions to be more accountable and transparent.
Public consultations over aspects of local healthcare have been criticised for not offering meaningful involvement or for being side-stepped altogether. CCG decisions, especially around reconfigurations have often ended up facing local campaigns and have ended up being examined in the courts on multiple occasions.
Undermine the NHS
Other critics take the view that integrated care contracts will break down the central principle of the NHS to provide healthcare to all in our community.
The contracts may exclude or limit access to some healthcare and suggest a drift towards some of the characteristics of US-style accountable care.
After pressure from campaigners ministers have ruled out the possibility that private companies would be allowed to run an entire integrated care system under contract, but there is continuing concern about their influence and control.
A briefing by Keep Our NHS Public raises concerns about how Accountable Care Organisations will cement the decay of public funding of the NHS and help to strip NHS assets, such as land and buildings.
Campaign groups across the country, such as South Warwickshire Keep our NHS Public and Save Southend NHS , are concerned that the merger decisions have been made to save money alone and will lead to services not being targeted at a local level.
The groups have also criticised a lack of consultation and about a future lack of transparency.
In Thurrock, the local council criticised NHS England’s “dreadful” proposals to merge the five clinical commissioning groups (CCGs) in south and mid-Essex. Thurrock Council fears the loss of local accountability and strong existing partnerships and that a more centralised approach, could mean the different needs of patients and local priorities in the five areas would not be fully taken into account.
There are also concerns that GPs already do not have sufficient input into CCG decisions, and this will only get worse as the size of the CCG increases.
The Public Accounts Committee heard that a study by the King’s Fund and the Nuffield Trust found only 28% of GP practices feel they can influence the decisions of CCGs.
Have local people been consulted on the proposals?
The mergers cannot take place without approval from the members of the CCGs.
There is some confusion, however, over how much consultation with the public is needed. In many areas consultations have not taken place, but areas that have consulted include Birmingham and Solihull, Wyre Forest, Bradford and District, and Nottinghamshire/Nottingham.
The public consultation in Birmingham for a merger that took place in 2018 was criticised by HealthWatch Solihull, as people felt they “did not have all the facts to allow them to make an informed decision.”
As reported in the Lowdown last week Lewisham Hospital campaigners are demanding that there be full public consultation on CCG merger plans – and they believe they have the law on their side. The campaigners have gone back to the amended NHS Act 2006 which (14G) stipulates that CCG mergers involve both the dissolution of the pre-existing CCGs and the formation of a new CCG.
They have found that according to the Regulations governing the implementation of the Act, dissolution of a CCG requires the CCG to seek the views of all the people in the CCG area.
What are Integrated Care Systems?
Integrated care is an attempt get organisations working together to meet the health needs of their local population.
Integrated Care Systems are part of new policy to redesign the NHS through the creation of a partnership of organisations to plan and deliver care; involving NHS providers, commissioners, local authorities, third sector and for-profit companies.
In some areas ICSs will develop a single contract and one organisation will be take the lead and be responsible for its delivery un-der a fixed budget and by subcontracting the delivery of care to range of NHS, charity and private providers.
Campaigners have objected to the new scope for privatisation, and the lack of public accountability of ICSs which have no legal standing under the current NHS legislation.
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