Clinical commissioning groups: a north-south divide?

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The hard work and long hours put in by GPs and managers in setting up clinical commissioning groups (CCGs) have, so far, paid off. All 211 CCGs have been authorised to take control of their commissioning budgets from the beginning of April – albeit with a range of conditions attached. These new organisations are a cornerstone of the government’s reforms and their success will be essential if the NHS is to meet the challenges it faces.

Four out of five CCGs failed to meet at least some of the NHS Commissioning Board’s authorisation criteria. As reported in a previous blog, the most common weaknesses included not having a clear and credible commissioning plan or a sufficiently detailed financial plan – an important requirement given that CCGs will be controlling more than £65 billion of public money.

Some of the conditions attached are minor formalities that will be dealt with quickly, for example through provision of simple advice or toolkits. Others represent more serious gaps in competence and will take time to address, with remedial measures including removal of certain functions or insertion of specific people into CCG management teams.

The graph below shows the distribution of the authorisation results, with each line representing one CCG. The vertical axis shows a composite score based on the number and severity of conditions applied. The higher the score, the worse the performance of the CCG in the authorisation process.

Distribution of CCG authorisation results

The wide variation in CCGs’ level of readiness might be explained by any number of local factors and issues encountered while setting up some CCGs. Interestingly, the variation is not related either to CCG size or to levels of deprivation in the local population. Small CCGs performed as well as larger CCGs, and CCGs in more deprived areas performed no worse and, if anything, slightly better than those serving affluent populations.

However, the results do show substantial regional variation. CCGs in the north of England received significantly fewer conditions, and at a lower level of severity. There is a four-fold variation between the median scores for CCGs in each of the NHS Commissioning Board’s four regions. Assuming that the authorisation process was conducted consistently across regions, and that the conditions attached provide a fair measure of CCGs’ level of competence, it appears that CCGs in the south and in the midlands and east have a particularly long way to go.

Median authorisation scores by region

The authorisation process for CCGs has been deliberately different from the equivalent process for foundation trusts – it has been framed more as a part of an ongoing developmental process. How long it will take for those at the end of the distribution to catch up is not clear.

Commissioning support units (CSUs) will play an important part in helping CCGs to overcome capability gaps. Based on the authorisation results, some CSUs will be taking on a bigger task than others. CCGs served by Hertfordshire and Essex CSU, for example, received on average more than 30 times as many conditions (weighted for severity as before) as those served by North of England CSU.

CCG leaders have invested considerable energy in responding to the requirements of the authorisation process. The real challenge, of course, begins now. Later this week we will publish an updated version of our analysis of the ten areas where commissioners can make the biggest impact on the quality and cost of patient care. An important message from this analysis is that success will depend on the strength of collaborative working between commissioners in CCGs, local authorities and the area teams of the NHS Commissioning Board. 

In particular, CCGs will need to work closely with area teams to support quality improvement in general practice itself. This is a sensitive issue but one that will need to be grappled with if they are to improve on the outcomes included in the CCG outcomes indicator set.

A joint research project being conducted by The King’s Fund and Nuffield Trust, due to be published in the summer, will explore the role of CCGs in primary care development, and examine the all-important relationship between CCGs and their member practices. It is the nature of this relationship that will largely determine whether CCGs achieve the widely held goal of being ‘different’ from primary care trusts.

CCGs have yet to prove whether they will succeed where their predecessors have failed. But as they take on their statutory powers, now is a good moment to pause and congratulate the thousands of clinicians and managers involved on the progress they have made so far.