First, there are some grounds for optimism. All of the 34 CCGs completing the process in the first wave have been authorised, in some cases unconditionally, but more often with specified conditions attached. So far, the NHS Commissioning Board has not found it necessary to use the more punitive measures and sanctions available to it.
The conditions that have been applied to the first wave of CCGs give an indication of where their strengths and weaknesses lie. Of the 119 criteria CCGs must meet, there were two which CCGs failed to satisfy far more commonly than any others:
- having a clear and credible plan that sets out draft commissioning intentions for 2013/14 and a high-level strategic plan for 2014/15
- having a detailed financial plan setting out how the CCG will achieve financial balance and operate within its management allowance.
Only 50 per cent of the first wave of CCGs were able to meet the first of these important requirements. One interpretation is that while CCGs have made significant progress in putting the basics in place and preparing to accept their new powers, some do not yet have a clear plan for how they will use these powers once authorised. The core challenge they face is to commission improved services for patients in a time of financial stringency, and there is still some distance to go before we can be confident that CCGs will be able to rise consistently to this challenge.
We also know that many CCGs are grappling with the tricky question of what it means to be a membership organisation. The first authoritative research on the early development of CCGs was published last month by the Policy Research Unit in Commissioning (PRUComm), and highlights the diverse approaches being taken towards this by different CCGs. Many smaller CCGs are working hard to be seen as being owned by their members, whereas in larger CCGs, the conceptualisation is often that the role of members is to select the governing body and grant them authority to act on their behalf.
Most CCGs are using some form of locality structure as a means of trying to create more local ownership over commissioning decisions. However, the PRUComm research suggests that there is a lack of clarity over the role of localities, in terms of which powers will be devolved. Delegating significant responsibilities and budgets to localities will not always be viable within the management cost allowance. Given this, there is a serious question over whether so-called ‘strong localities’ will be able to live up to their name.
The research also suggests that some CCGs are struggling to find the right balance between being a membership organisation and playing a leadership role in developing primary care. There is considerable nervousness over this, with CCGs not wanting to alienate members by appearing to performance manage them.
The commitment, energy and skill shown by GPs across the country in getting CCGs to their current level of development should not be underestimated. Over the next two years, further light will be shed on the challenges faced by CCGs, as well as their successes, by a major research project being conducted by The King’s Fund in partnership with the Nuffield Trust. The research is following a group of selected CCGs across the country as they evolve. Our first results – due for publication in summer 2013 – will tell us more about this critical part of the new system architecture.
- See our work on commissioning
- Find out more about our research project with the Nuffield Trust: The evolution of clinical commissioning: learning from local experience