Clinical commissioning groups: does size matter?

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We are in the middle of what has become known as the 'configuration risk assessment'. A process led by strategic health authorities, each clinical commissioning group has been asked to assess itself against four criteria; member ownership; boundaries in relationship to local authorities; geographical boundaries for effective commissioning; and size to effectively commission.

Clinical commissioning groups are fundamentally member organisations, and in similar organisations, it is the members who determine the configuration. Attempting to force these configurations will only lead to members feeling like they are not in charge.

This is the first challenge that clinical commissioning groups face and, if they are unable to address this issue, why should we expect them to succeed at the more challenging issues that commissioning will send their way? There is no simple answer, but the roots of the solution lie in collaboration.

The question concerning effective boundaries for commissioning has been clarified recently by David Nicholson's statement that mosaic structures – where one clinical commissioning group has a practice from another clinical commissioning group locality within it – would not be acceptable. Clearly pragmatism would apply and those on the borders considered in light of patient flows and the views of the clinical commissioners.

However another question – that of size – has prompted many to call for the protection of the smaller commissioning groups. And with the recent announcement of a running cost allowance of £25 per head in the clinical population, there is also an intense focus on affordability. With each statutory clinical commissioning group having fixed costs (such as governing body and audit fees) it implies that the smaller the group, the smaller the amount left from this allowance to use for all the other commissioning functions.

In addition to the argument that larger groups can achieve economies of scale, the history of commissioning, here and internationally, suggests that in order to manage financial risk, groups need to be large. There is also a strong case for bigger groups if they are to lead reconfiguration and drive significant change in the shape and pattern of services.

So would small groups really be able to deliver the change we seek? An observation – call it anecdotal, but it chimes with experience – is that smaller groups seem to develop a sense of ownership quickly, enabling change to occur at a local level. This seems harder to develop across larger groups, where the clinicians may be from different communities and are not necessarily like-minded. Does this higher level of engagement from smaller clinical commissioning groups translate into added value?

We have seen many examples of smaller groups coming together under the umbrella of a single clinical commissioning group; Cumbria, and Cambridge and Peterborough being two examples. These groups benefit from sharing the fixed costs, yet retaining locality autonomy. Most examples are groups that have been working for some time to develop local ownership and infrastructure, giving a great deal of thought to how risk will be managed across the group. In particular, they seem to have developed a high degree of internal trust.

Given the policy and economic pressures to form larger clinical commissioning groups, one solution may be for like-minded practices to form into provider federations at locality level. Over time, these practices could take limited financial risks through capitated payments from the clinical commissioning group to take greater responsibility for the financial consequences of their decisions and the quality of care they deliver to their patients.

The desire to come out with a number – the minimum size for a clinical commissioning group – is tempting, but it would be misleading, as the outputs of clinical commissioning groups depend on many factors. You can certainly envisage that smaller clinical commissioning groups who work successfully across boundaries may be more effective than larger groups that fail to collaborate.

So while size may be a factor, it is the ability to work across organisational and sector boundaries that will help clinical commissioning groups to achieve their goals. This will ensure the evolution of our NHS and the transformational change needed. After all, our patients rarely understand the strange and artificial boundaries that we place in front of them anyway.


Felix Greaves

Imperial College London
Comment date
04 January 2012
We've just completed an analysis looking at the same question, published in the British Journal of General Practice this week and it comes to a similar conclusion.

We looked at the performance of PCTs over the last few years, and compared them with their population size. We found no evidence that their performance was related to size across a number of domains including measures of clinical and preventative effectiveness, patient centredness, access, cost, financial ability, and engagement.

This suggests that you can't name an optimum size for a CCG, at least in the size range of PCTs before clustering took place (about 100,000 to 1 million people).

GPs should therefore think about what would work well in their local area, rather than being shoehorned into a particular population size for their CCG.

Mike O'Neil

Nottingham West CCG
Comment date
04 January 2012
An alternative model for small groups is to have small CCGs sharing some significant resources (some personnel, some financial risks). That has the advantage of autonomy for the the groups from the beginning. Our estimates suggest population sizes around 100,000 can be sustained on this model. As you conclude the key thing is that there is freedom for us to experiment to find the most effective models.

Michael West

Professor of Organizational Psychology,
Lancaster University
Comment date
05 January 2012
Outside the NHS, there is much interest in entitites called multi-team systems and how they operate. They are organizatons made up of teams that interact and feed into the overall decision making body - also a team. Key is clarity about objectives, effective participation in decision making and communication and reflexivity (learning from information and decisions and then making appropriate changes). There is much to learn for commissioning groups from the work on mult-team systems and from a parallel consideration of the organizational literature on strategic leadership. The leadership of these commissioning groups by the executive teams will be critical.
Teamwork in Multiteam Systems.
Marks, Michelle A.;DeChurch, Leslie A.;Mathieu, John E.;Panzer, Frederick J.;Alonso, Alexander
Journal of Applied Psychology, Vol 90(5), Sep 2005, 964-971. doi: 10.1037/0021-9010.90.5.964
An examination of the effects of organizational district and team contexts on team processes and performance: a meso-mediational model
John E. Mathieu1,*, M. Travis Maynard2, Scott R. Taylor3, Lucy L. Gilson1, Thomas M. Ruddy4Article first published online: 23 SEP 2007

DOI: 10.1002/job.480

Copyright © 2007 John Wiley & Sons, Ltd.
Journal of Organizational Behavior
Volume 28, Issue 7, pages 891–910, October 2007

Ben Gowland

Chief Executive,
Nene Commissioning
Comment date
08 January 2012
The more serious concern to the future success of clinical commissioning is presented by the large number of CCGs with a population size around 200,000. Here you have a group that is unlikely to create any locality style model to drive grass roots engagement, which will be the critical success factor for any CCG. Meeting as a single group of 20, 30 or 40 practices creates too much opportunity for non-participants to hide, and places far too much reliance on a very small number of clinical leaders. More emphasis and support must be given centrally to helping CCGs set up effective locality structures to ensure we create a new system of commissioning that is significantly different to that which went before.

Mary E Hoult

Comment date
09 January 2012
I have followed the Cambridge and Peterborough progress for over 5 years and don't feel their profile is deserved !!! only time will tell the real outcome !!!but by them the people responsible will have flown the nest.
have we no other role models?

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