Just weeks after Health Secretary Matt Hancock and NHS England finally scrapped their long-running efforts to reconfigure hospital services and close Ealing and Charing Cross Hospitals, North West London health chiefs might sensibly have stayed quiet for a while, or even better offered an apology to local people for the money and effort wasted since 2012.

Instead they have already floated another controversial plan. This time they want to merge all eight CCGs in NW London into one mega CCG covering 2.2 million people and a patch stretching from Heathrow Airport to the middle of London, and from Putney to the M25.

The very notion of this as being in any way “local” or responsive to communities within this large area is laughable. It is very different indeed from the verbal commitment to localism that was used to sell the 2012 Health and Social Care Act, which set up the CCGs, and remains the legal framework of the NHS.

In fact it seems that a major attraction of the merger is likely to be hopes of being able to push through controversial plans by outvoting any CCGs and local boroughs which disagree, as NW London health chiefs tried to do with their “Shaping a Healthier Future” (SaHF) project until it was belatedly killed off.

Even at a time when other CCGs have been merging, its 2.2 million population would make NW London CCG an enormous monster, with more than double the population of the Devon CCGs that merged last year, and 1 million more than Birmingham and Solihull. The paper arguing the case for the merger predictably cites the NHS Long term Plan, which vaguely called for each Integrated Care System to relate to a single CCG.

NHS England guidance

But it conveniently ignores specific NHS England guidance on CCG mergers that has been published since the Long Term Plan, and it’s plain to see from the characteristically evasive language they use that the CCGs cannot answer many of the key issues raised in that guidance.

The guidance stresses that NHSE alone has the power to agree or reject an application for a merger, and there is no right of appeal. It is supposed to seek evidence on the extent to which the proposers have has sought the views of local authorities and other relevant bodies, “what those views are, and how the CCG has taken them into account”. (p8)

In addition NHS England calls for evidence on

“the extent to which the CCG has sought the views of patients and the public; what those views are; and how the CCG has taken them into account;”

Since the track record of NW London CCGs on seeking and taking on board any critical views from local authorities or the public was appalling throughout the long-drawn out effort to push through SaHF – for which they have still not apologised or been called to account – there is little reason to suppose they will do any better now.

Indeed the insistence on pushing through those plans led to two of the eight boroughs, Hammersmith & Fulham and Ealing, refusing in 2016 to support the Sustainability and Transformation Plan which mirrored the SAHF proposals.

That’s why on page 6 of the document the CCGs state that the health and care system in NW London comprises 30 organisations including only six local authorities. On page 8 they concede that the area includes eight local boroughs. However at no point is this discrepancy discussed: instead the document claims evasively that the NHS

“will need to be clear about the strategic role of the integrated care system, operating at NW London level, and how we will work with our local authority partners in integrated care partnerships at borough level.” (p8)

Councils left out?

Are Hammersmith & Fulham and Ealing included as “local authority partners” – or ignored?

The document predictably argues that a mega-merger could save money on admin costs, while downplaying any possible loss of jobs for CCG staff and claiming that they would retain “a strong and visible local representation in each borough”.

But given that the entire operating cost of all eight CCGs is admitted to be no higher than £5.4m a year, £680,000 per CCG, even scrapping all of them completely would save just 0.2% of NW London CCGs’ £2.9 billion combined budget. If this microscopic saving comes at the expense of any real accountability to local communities it’s a poor trade-off.

There are many more weaknesses that could be highlighted in the 24-page document: but the biggest flaw of all is that it fails to address any of the key questions raised by NHS England’s guidance, which states (page 10):

“The existing CCGs must demonstrate how the merger would be in the best interests of the population which the new CCG would cover. This is particularly important in any case where the boundary of the proposed new CCG is not coterminous with local authority boundaries.

“In all cases, in line with the legal requirements, the existing CCGs must demonstrate in their application that they have effectively consulted with the relevant local authority(ies) regarding the proposed merger, record what the local authority(ies)’ views are, and what the CCGs’ observations on those views are.

“They should also show how they have/will put in place suitable arrangements with local authorities to support integration at ‘place’ level (population of between 250,000 and 500,000).” Nor do the CCGs appear to have answers to questions they themselves raise in the document, such as:

  • What safeguards would a single CCG need to ensure it was responsive to local needs?
  • What considerations should there be about a single CCG governance arrangements?
  • How do we get a strong public voice into a CCG at NW London level? (p9)
  • How do we ensure that the local voice is strengthened?
  • The local partnership between health and local authorities will be key to delivering the outcomes the NHS Long Term Plan – how do we ensure this is most effective?
  • What level of integration is appropriate and achievable? (p12)
  • How will we engage with patients/public at local level?
  • How would patients and residents be involved in decision-making?
  • How should we maintain local accountability?” – p15
  • How can we maintain staff morale and retention through this period of change? (p17)

How indeed? With more questions than answers, and a track record of indifference to local views, it would not be surprising if a groundswell of opposition to this merger plan emerged in NW London – inspiring similar challenges elsewhere, including the equally half-baked plans across the river to merge six South West London CCGs into one.

John Lister
Author

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