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.
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.
Comments
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.
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.
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 !
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' !).
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 ?
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