The NHS Long Term Plan is the latest change in three decades of changes to the structure of NHS commissioning organisations. The Long Term Plan sets out the intention for Integrated Care Systems to cover the whole of England by 2021. This will result in a significant reduction in the number of Clinical Commissioning Groups (CCGs).
The changes in organisational structures since 2012 have been particularly confusing and rapid. The changes make it challenging for taxpayers to understand who in their local area is accountable for health spending and performance.
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 and to make this transparent to the public. The alphabet soup of health bodies that has grown up has done so, in many instances, without clear governance and accountability.
Many CCGs are currently underperforming and this will need to improve as they take on the responsibility for commissioning services across larger populations.
Getting the commissioning structures right will be an important part of delivering the NHS Long Term Plan. This will need to include: establishing appropriate structures for Integrated Care Systems and CCGs; ensuring CCGs take account of the needs of local populations as commissioning is undertaken at a larger scale; having clear accountability structures in place as planning and commissioning decisions are made jointly across the organisations within Integrated Care Systems; and ensuring legislative changes support the delivery of the NHS Long Term Plan.
At the same time the public need to know how these changes will benefit healthcare and health outcomes in their area.
"Time and again our committee has seen reforms that are driven by good intentions fail to result in positive outcomes.
“That fate must not befall the latest changes to commissioning in the NHS, which need to deliver frontline benefits, safeguard public money and avoid further muddling lines of accountability at local level.
“This will be a challenge. NHS England rated the performance of four in every 10 CCGs as either inadequate or requiring improvement last year.
“Standards must improve significantly as CCGs take on the commissioning of services across larger populations – a change which runs the risk of them losing focus on the particular healthcare needs of local people.
“We will follow developments with interest and expect NHS England to provide us with a detailed update by the end of the year.”
Conclusions and recommendations
We are concerned about the impact on patient outcomes if the performance of CCGs does not improve, especially as they become responsible for commissioning services across larger populations. NHS England undertakes an annual assessment of CCGs as part of its oversight function. In 2017-18, 42% of CCGs were rated either 'requires improvement' or inadequate'. While performance ratings have improved since 2015-16, the assessment methodology has changed meaning a direct comparison is not possible. NHS England currently deems 24 CCGs to be failing, or at risk of failing. NHS England works with NHS Clinical Commissioners to provide support to CCGs to help them improve. Recruiting and retaining high quality leaders is a major challenge for CCGs. CCGs have responded to this challenge with eight formal mergers since 2013. Increasingly, CCGs have joint senior management teams and most share an accountable officer with at least one other CCG. NHS England has taken action to replace some management teams to improve performance.
Recommendation: NHS England should report back to us by the end of 2019 on the actions it has taken to ensure all CCGs are performing effectively and have high quality leadership as they take on responsibility for commissioning across larger populations.
It is not clear how many CCGs there will be by 2021, or the final structure of Integrated Care Systems. The number of CCGs is likely to reduce significantly by 2021. Typically, there will be one CCG for each Integrated Care System although there will need to be flexibility to take account of local circumstances. While Integrated Care Systems will develop from the current structure of 42 Sustainability and Transformation Partnerships, further work is required to determine the final structure of Integrated Care Systems. The Department and NHS England see this as an evolutionary process run by local NHS organisations rather than a top-down process. However, NHS England says it will step in where it has concerns about the effectiveness of local structures. CCGs need to make 20% reductions to their running costs by 2020-21. There may be cost savings potential from greater collaboration between CCGs. Any redundancy costs will have to be covered by CCGs within the year they are incurred.
Recommendation: When reporting back to us at the end of 2019, NHS England should provide an update on what it expects the structure of NHS commissioning to be by 2021. This should include: how local circumstances are being taken into account as it determines the structure of CCGs and Integrated Care Systems; an update on the expected number of CCGs; the number and configuration of Integrated Care Systems; and an estimate of the redundancy costs CCGs will incur.
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. While a King's Fund / Nuffield Trust study found that the introduction of CCGs had increased clinical engagement in commissioning, only 28% of GP practices felt they could influence the decisions of CCGs. NHS England is looking at a three-tiered approach to planning and commissioning services across a population and also at the development of GP networks to help plan and reshape services at a local level. We are also concerned about how patients will understand who makes decisions and keeps a close eye on the local NHS finances.
Recommendation: When reporting back to us at the end of 2019, NHS England should set out the actions it has taken to ensure that local GPs have input into CCGs' decisions and that CCGs remain focussed on the needs of local populations as they cover larger populations.
We are concerned that, as Integrated Care Systems develop, accountability systems will be weakened and the performance of individual CCGs will become less transparent. Currently accountability systems are based around statutory bodies with CCGs accountable to NHS England. As part of its oversight function, NHS England undertakes an annual assessment of CCGs' performance. However, Integrated Care Systems are non-statutory partnerships of NHS organisations (commissioners and providers), local authorities and other organisations. The organisations within each Integrated Care System will take collective responsibility for improving the health of their population. In turn, NHS England's assessment framework is moving towards assessing health systems rather than individual organisations. We welcome the move towards more integrated planning and commissioning of health services. However, 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.
Recommendation: The Department should, in its next accounting officer systems statement, expand on the current description of Integrated Care Systems and how they will be held to account for their joint decisions and responsibility for improving the health of their population.
Delivery of the NHS Long Term Plan will be slowed without legislative changes. NHS England has set out in its NHS Long Term Plan changes to legislation that would free up NHS bodies to help to deliver its plan - including legislation that would support the effective running of Integrated Care Systems by letting NHS trusts and CCGs make joint decisions, and freeing up NHS commissioners to decide the circumstances in which they use procurement processes. NHS England thinks it could still deliver the NHS Long Term Plan without legislative changes. However, progress would be quicker with changes to legislation. The Department welcomes the proposals for legislative changes from NHS England and it will be for Government to consider and bring forward changes to legislation.
Recommendation: The Department should ensure that required legislative changes are developed and brought forward in a timely way so that progress on the NHS Long Term Plan is not delayed.