CCGs: system change

Set up in 2013 under then health secretary Andrew Lansley’s Health and Social Care Act 2012, CCGs became the cornerstone of commissioning services in the NHS in England, responsible for spending around £80bn in 2019/20 (about two-thirds of the NHS England budget). In 2013 there were 211 CCGs, though their numbers have gradually reduced in recent years as the bodies merged – before this April there were 135.

The vision was that these statutory bodies would be clinically led, with local GPs largely cast in the leadership role. More controversially, they would also foster competition, buying patient care from NHS, social enterprises, voluntary organisations and private providers to suit local patients’ needs.

But less than a decade since they were formed, they are being replaced by integrated care systems (ICSs) as the NHS in England moves to a system-wide collaborative model. From 1 April there are 42 ICSs and, though they are not yet statutory bodies, they will play an increasing role in commissioning this year.

Hailing the confirmation of all 42 ICSs last month, NHS chief executive Simon Stevens (pictured) said: ‘Partnership working has been at the heart of the NHS’s remarkable response to the coronavirus pandemic and the NHS vaccination programme.

‘We have seen what the NHS pulling together can do in the most testing period in the health service’s history. The establishment of ICSs across the country will help to ensure that agile approach and can-do attitude endures beyond the pandemic.’

Amanda Pritchard, NHS England and Improvement chief operating officer, added: ‘This milestone is a great achievement, which shows the strength of system collaboration across the country. The ICSs have proven their value over the past year and will play an increasingly important role in the restoration, recovery and transformation of services for the benefit of patients and citizens.’

White paper

A government white paper published in February said that from April 2022 each ICS will have a statutory ICS NHS body and a statutory ICS health and care partnership. The latter will bring together NHS providers, local authorities and other organisations, such as those in the voluntary sector, to plan for the system’s wider health and care needs. Last week, the NHS Confederation called for clarity on governance and accountability of the ICS NHS body and the health and care partnership, including their statutory roles.

The ICS NHS body will subsume CCG commissioning functions, for services such as secondary care services and mental healthcare, as well as some direct commissioning for specialised services previously operated by NHS England. ICSs will also seek to foster greater co-operation between NHS organisations, local authorities, the third sector and others, though some competition will be possible if appropriate for local needs.

The white paper insisted the primary care voice would not be lost, but would be enhanced by adding those of clinicians in community, acute and mental health providers, as well as public health and social care.

Under the proposed reforms, the 42 ICSs are due to be given statutory status from April 2022, generally coterminous with higher tier local authorities. But, as of 1 April this year, there are 106 CCGs, even though 38 CCGs were involved in mergers at the beginning of April, forming nine CCGs in the process. The task now will be to quickly move to a single decision-making structure in each of the 42 ICSs.

In many ICS patches there will already be one executive team, either by having a single CCG or with the same group of directors covering a number of CCGs that have not formally merged. NHS England has set out a path to ensure that all commissioning functions are organised at ICS level during 2021/22. In its ICS implementation guidance for 2021/22, NHS England said ICSs with multiple CCGs must confirm that governance and resourcing arrangements are in place to ensure single commissioning decision-making and that ICSs operate effectively as a single management team.

By quarter 3 CCGs should only operate at ‘sub-ICS level’, where the ICS system development plan sets out the intention to establish a significant place-based function at the CCG footprint. Primary and community service development and the implementation of population health management will be based at place level, using existing primary care networks (PCNs) as building blocks for local integration.

CCG collaboration

A spokesperson for NHS Clinical Commissioners, which represents the majority of CCGs, said: ‘2021 is very much a transition year for CCGs as they look at the content of the government white paper and await the expected bill in May, and we are very much supporting our members through this transition. Much is still to be clarified in both the expected draft legislation and guidance, for example what happens exactly about transferring CCG staff, particularly at board level.’

King’s Fund senior policy advisor Anna Charles (pictured) said CCGs will be expected to meet their statutory duties in 2021/22, including key national standards such as the mental health investment standard. They must also support system transformation and improvement, by, for example, supporting PCN development and contributing to the development of ICSs and place-based partnerships.'

She added: ‘National documents have set clear expectations that CCGs will need to collaborate more closely with local partners to identify and implement shared system priorities. This includes working more closely alongside providers – moving away from a transactional relationship based on annual contracting rounds – with providers playing greater role in decisions about service change and pathway redesign.’

Larger CCGs are likely to begin organising staff and functions around smaller footprints, exploring how decisions and resources could be delegated to these locality or place levels, Ms Charles said. Delegation could help avoid the reforms undermining place-based working. She added that the reforms could bring benefits in the form of a strategic approach to commissioning, but there was a risk of disruption as the new structure is established, and at a time when the NHS is under pressure.

Board membership

NHS England and NHS Improvement have committed to retaining CCG staff below board level who are directly affected by the move to ICSs. Local NHS administrative costs will not be cut as a result of the organisational changes. This could help minimise disruption through retaining skills and experience.

The white paper said each ICS unitary board will, at a minimum, have a chair and an accountable officer (chief executive), though the NHS England and NHS Improvement implementation guidance said ICSs should also appoint a chief financial officer. There have already been calls for boards to include clinical and lay members and for their membership to include representatives of particular sectors, such as mental health.

NHS Clinical Commissioners believes that generally ICSs will have board-level CFOs. ‘Our understanding is that the legislation is intended to be enabling and flexible, and we would be looking for systems to be able to determine what roles they would need at board or senior level as this may vary from system to system, though it would seem in most cases appropriate that the CFO of an ICS would be part of that structure.’

How will history view CCGs? NHS Clinical Commissioners acknowledges they are not a neutral party, but added: ‘We’re pretty bound to say there is much that has worked well in CCGs that we would want to see carried forward into ICSs as the CCG legacy. The prominence and role of clinical leadership in commissioning is one aspect we would very much want to see taken forward and is part of what we will be seeking to influence on.

‘CCGs are the starting bedrock of ICSs. We would certainly hope to retain the strategic commissioning expertise in the new landscape, and we hope many existing and future ICS leaders are and will be from a CCG background, so the hope is that the positive CCG legacy will live on.’