CCGs and PCTs - not so different after all?

There will be important differences between clinical commissioning groups (CCGs) and primary care trusts (PCTs) – it could hardly be otherwise, given the radically different context in which CCGs will be operating. But in terms of the population size they cover – a hugely significant issue for any commissioning body – CCGs and PCTs look increasingly similar.

We have known for some weeks now that the average size of CCGs looks set to be considerably larger than originally anticipated – the median population covered by the 212 CCGs preparing for authorisation is 226,000, compared to 284,000 for the 151 PCTs they replace.

But many have assumed that while the average size of CCGs may not be so different, one thing that will be different is the degree of variation. The analysis below shows that this is not the case.

There is certainly significant variation between CCGs – with a 13-fold difference between the biggest and the smallest. But what is often missed is that the same is true with PCTs – Hampshire PCT covers a population 14 times larger than Hartlepool PCT.

The graphs below illustrate this similarity. In the first, each line represents one PCT or CCG (figure one). In the second, the horizontal axis has been standardised to allow direct comparison (figure two). What these figures show is that the distribution of CCG sizes – though not exactly the same – is not as dissimilar from PCTs as we may have thought.

Click on the graphs below to expand.

Figure one: Comparison of CCG and PCT population size (raw data)


Figure two: Comparison of CCG and PCT population size (standardised)


There are, however, some important caveats to bear in mind

First, management resources will be lower for CCGs, and as a result of this more of their functions will be shared between CCGs or delegated to commissioning support services and other organisations. So the organisations themselves will be smaller than PCTs even if the population size they cover is comparable. In some cases the extent of sharing or delegation of commissioning functions may raise the question of whether the size of each individual CCG is the most important issue.

Second, while the degree of variability may be similar for CCGs and PCTs, the factors driving it could be very different. PCTs are administrative constructs, whereas the shape and size of CCGs has been influenced by a number of factors, including clinical flows, perceived ‘natural’ population groups, the pattern of professional relationships across a local area, and existing administrative boundaries. A CCG may be small (or large) for different reasons than those that determine PCT size.

The analysis shown here does not imply that the way CCGs function or the outcomes they achieve will be comparable to PCTs – that remains to be seen. What it does illustrate is how pragmatic considerations can shape the implementation of policy and take it in very different directions from those originally envisaged.

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#1281 Mike Stone

'and take it in very different directions from those originally envisaged'

Are you sure, about exactly what was originally envisaged ?

I 'gleaned an understanding', that one of the functions of the 2 statutory lay persons, and the one statutory nurse, on CCBs was to introduce a different perspective from, and independence from inappropriate influence by, the GPs on the CCBs. That would seem to require, either small CCGs, or 'intertwining' of CCGs, so that these people could truly be 'arms length' from any of the GP Surgeries within that particular CCG/B.

That is very tricky, with single CCGs covering entire cities - or did I misunderstand something ?

#1282 Ben Bray
Research Fellow

The last paragraphs are thought provoking. CCGs seem to have developed in a more "emergent" manner than did PCTs. In a complex organisation like the NHS, it is possible that this might have some benefits over a more planned, top down approach...will be interesting to see how this pans out.

#1283 R Hamilton

CCGs also have fewer staff because they don't have public health departments, don't commission specialised services, offender health, general practice, optometry, or dentistry!

#1284 Geraint Lewis

Great blog, Chris. It would be great to follow up with an analysis of income distribution - whether CCGs are more or less socioeconomically homogeneous than PCTs. I think there's an assumption that they are, but it would be good to test.

#1285 calum paton
Professor of Public Policy
Keele University

Very useful, Chris - thanks.

One thought: who 'expected' or 'anticipated' that CCGs would be substantially different...may I suggest that such expectations represent a failure to learn from the history of NHS re-disorganizations (in Alan Maynard's nice term.) Or to put it another way: implementation consistent with public governance and 'planning' of a public service was bound to reveal that Lansley was living in La La Land.

#1286 Jackie Tizzard
General & Development Manager
Phoenix Homes Colchester

More information like this please! Especially on Essex (previously NE Essex PCT)

#1287 Mike Stone

'One thought: who 'expected' or 'anticipated' that CCGs would be substantially different.'

Calum, are you somewhat cynical, in a sort of 'general way', as I am, then ? Or was that a narrow point, that the institutions invariably get in the way of things like 'bottom-up' control ? And that you cannot easily have at the same time responsibility at the top, and decisions at the coal-face ?

I do sometimes struggle, with claims made that 'this evidence supports our view', when I often cannot see a direct connection between the quoted evidence, and the policy change it is claimed to support.

#1288 Mike Nicholls

CCGs must be very like PCTs since they will carry out many of the same functions. Doctors on the CCGs will essentially be board members, one or two enthusiasts in a CCG may spend much of their time with the CCG, but for the majority of doctors the CCG will be peripheral to their work as doctors.. If a change in the balance of services is proposed by one practice someone still has to look at demand across the CCG, waiting times, use of specialist facilities etc., in order that a decision is taken on the basis of evidence,

#1289 Chris Naylor
The King's Fund

Thanks everyone for the comments. Calum Paton and Mike Stone both raise a question about what was originally envisaged. Clearly different people have held diverse expectations about CCGs, but there was certainly an initial feeling among many that CCGs (or GPCCs, as they were set to be at the time) would be significantly smaller and more numerous than PCTs. The government always carefully refused to give a number, but early indications were that there could be over 400. The management allowance made that unfeasible.

#1294 Mike Stone

'Chris Naylor - Fellow, The King's Fund
20 Jul 12'

Chris, you know much more about this than I do. But I can remember 'trial groups of GP Surgeries' 'proving the concept works' as a claim coming from ministers - so were any of those trial groups of GPs, anything like even 1/400th of the country ?

If not, what exactly were they proof of - it cannot have been of the likely success for a system with CCGs of the type of size you mention, surely ?

#1295 Chris Naylor
The King's Fund

Yes those were the so-called "pathfinder" consortia. The average size of the pathfinders was slightly smaller that the final list of CCGs. Some of them were much smaller, in fact, but financial viability led to the smaller groups merging with others.

#1296 Mike Stone

Thank you for the info, Chris.

But it isn't, in my view, the same 'system' as Cameron et al 'sold' to the public, because the implication was definitely 'you and your GP will be more directly in control of the 'services purchased' for you to use - I cannot square that, with the large size of CCG/Bs, even if it isn't possible for them to be smaller (it was never clear, why GPs should be directly purchasing secondary services, as that would take up an awful lot of rtheir time, and probably be outside their skills range - but I think that was the impression ministers were conveying to the public, and if it was clearly a non-runner, that was a straightforward 'con job' !).

#1297 chris packham

pretty much similar but with two signficant differences CCGs have less commissioning breadth (they cant commission primary care any more) and specailised commissioning that was done on their behalf will now be done by NHSCB (so much less local influence) and CCGs will loose the bulk of their public health technical advice to help prepare healthcare commissoning assessments and the inevitable rationing they will be doing from this coming year. So a more fragmented commissioning landscape with less influence and less technical support. Tough times ahead.

#1298 Mike Stone

'So a more fragmented commissioning landscape with less influence and less technical support.'

Yep, that was my impression of the Act as it eventually passed, with all of these 'layers/bodies' inside it - but it wasn't being sold to me (or to nurses, so far as I can work out from the NT site) as something which would lead to that ! It looks like a complete dog's breakfast, speaking as someone who has followed it not in great depth.

And I still think of the group of GPs as being the CCG, and the board commissioning services on its behalf as the CCB associated with that particular CCG - the terminology being used, is perplexing and unhelpful, and seemed to have been altered for the worse during the debate about the Bill !

#1299 F Blogs

what your article doesn't refer to is the very probable scenario that there will be significant CGG mergers during the first couple of years of operating driven by management cost constraints which is highly liklely I'd dare to suggest to result in CCGs with v similar boundaries to the existing 50-odd PCT clusters

#1369 Christine Hall ...
fee paid tribunal MHRT judge

I applied for the lay commissioner appointment for the North Lancashire CCG. The advert was fro someone local and they appointed a person from outside the commissioning area. Apparently the interviewing panel was impressed by her ideas to deliver hospice care in the home and to make it affordable by using volunteers.
It seems there is still a close link with the PCT in that the medical director of our PCT is to be moved sideways to be chair of the commissioning board.

#40527 Alison Hornsbury
Volunteer member of local commissioning group CATCH
Cambridgeshire association to commission health

Patient say within health care locally has been substantially reduced by the recent changes.
Living in Cambridgeshire our CCG now includes Peterborough and is therefore much bigger than the old PCT and is the second largest in the country. To make sense of the size and huge diversity of population from the healthy and relatively affluent Cambridge City and South Cambridgeshire to the real deprivation in parts of the north of the county a structure of 8 Local Commissioning Groups (LCGs) was established underneath the CCG which vary hugely in size from Wisbech with just 4 practices and a relatively tiny population to the group I am in which covers most (but not all) of Cambridge City and South with 28 practices and a population of approx 220,000, bigger than the median size of CCGs. Our patient group has the same voice at CCG level as the group of 4 practices, surely this is wrong? The level of patient involvement in this big group is a real problem. There are no board meetings in public as the doctors feel that this would 'be worrying to patients to hear things that may not have been decided!' and the statutory 2 patient representatives on the Board are not allowed to report to the patient group (made up of representatives from each practice) as they have been asked to keep all issues completely confidential.
The doctors working in the new structure are trying their best but we have no say at CCG level at all and there is real fear at the more local level. This is not a small issue. Our group is the lead in commissioning the services from Addenbrooke's which is one of the largest hospitals in Europe but where is the patient involvement. We are moving backwards not forwards but it is clear that the administrative and professional support for the teams are hugely reduced. I fear for the future despite recognising that everyone concerned is really trying to do their best.

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