A big problem for the NHS: reconciling local independence with central control

In recent years, the English NHS’s structure has been quietly revamped and many CCG functions dispersed – leading to a bewildering array of acronyms.

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Clinical Commissioning Groups (CCGs) are statutory bodies established under Andrew Lansley’s 2012 Health and Social Care Act. There are around 200 of them in England (the devolved nations have different arrangements) and they assumed responsibility for the bulk of NHS services in their local areas in April 2013. Yet even though they have just marked their sixth birthday, there won’t have been much celebrating. CCGs are currently in their death throes.

There has been no new legislation underpinning the changes and CCGs will continue to exist in name until there is. But over the past couple of years, the structure of the English NHS has been quietly revamped and many CCG functions are being dispersed. The bewildering array of acronyms can make one’s eyes glaze over. We’re witnessing yet another chapter in the interminable struggle to reconcile local independence with central control, a dilemma that has dogged the NHS for three decades.

The received wisdom ever since 1990, when the Thatcher government created the NHS “internal market”, is that local clinicians should be given control over their own budgets because they are best placed to know what their populations need. The original model, GP fundholding, which was taken up by around half of practices, was arguably the most successful, but it proved contentious. It led to a two-tier system: patients of fundholding practices received faster access to services because of the financial clout that their doctors wielded. And there was a conflict of interest built into the scheme, whereby savings made against budgets could be reinvested by fundholders to improve their own practices. Too much local control. The centre took over again.

There followed a couple of models that attempted to harness clinician input into more traditional health authority organisations – firstly primary care groups (PCGs), latterly primary care trusts (PCTs) – but these proved unsuccessful, with the dead hand of bureaucracy stifling clinically inspired innovation. Lansley’s CCGs were intended as a corrective, once more returning the reins to local clinicians. But paranoia over conflicts of interest saw CCG clinicians excluded from important decisions, which were taken solely by managers. In our own area, this led to two disastrous contracting-out misadventures that materially worsened services for patients and destroyed decades’ worth of goodwill from staff. CCGs were born in the austerity era. By April 2018, two-thirds of them were in deficit. The centre has once again stepped in.

The latest iteration will split power two ways. The bulk will be concentrated in regional bodies called integrated care systems (ICSs), responsible for populations of up to 2 million. But as a nod to the notion of local control, practices are being grouped into primary care networks (PCNs) covering 30,000-50,000 patients, with modest budgets to shape some services in their area – albeit that the kinds of provision they can make are being tightly determined by the centre.

As with any restructuring of the NHS, there are theoretical reasons to suppose the new arrangements might be a good idea. ICSs are being jointly formed by both the NHS and local authorities, which provide social care, and they will involve community and voluntary sector organisations as well. And PCNs might allow some service innovation at the local level – assuming they’re not smothered by bureaucracy.

This latest change is yet another cycle in the continual revolution the NHS has been experiencing for decades. Staff in our local CCG are exhausted; turnover is at epidemic rates – sickness absence, too. Those souls whose careers have spanned PCGs, PCTs and latterly CCGs are wearily braced for the coming upheaval, certain in the knowledge that when the government next changes there will be billions more spent on yet another bright new restructuring. If there’s one thing that can be said of all incarnations of NHS organisation it’s that they shall not grow old. 

Phil Whitaker is a GP and the New Statesman’s medical editor. His books include Chicken Unga Fever: Stories from the Medical Frontline (Salt)

This article appears in the 03 May 2019 issue of the New Statesman, A very British scandal

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