Spending watchdog concern at proportion of CCGs failing to function effectively

Many clinical commissioning groups (CCGs) are performing well and within budget but others are failing to function effectively or hire and retain the high-quality staff they need, the National Audit Office has warned.

The head of the spending watchdog, Amyas Morse, has also called for an end to the continual restructuring of NHS commissioning.

In its report, A review of the role and costs of clinical commissioning groups, the NAO noted that over half of CCGs were rated by NHS England as either ‘outstanding’ or ‘good’ in 2017-18, but more than 40% were rated as either ‘requires improvement’ or ‘inadequate’, with 24 CCGs deemed to be failing, or at risk of failing.

“While most stakeholders provide a positive view of their engagement with CCGs, neither the Department of Health and Social Care nor NHS England have undertaken an overall assessment of CCGs’ progress in achieving their policy objectives since they were introduced,” the watchdog said.

The report found that an increasing number of CCGs had been overspending against their total budget plan.

In 2017-18, 75 of 207 CCGs (36%) spent more than planned with a total overspend of £213m across all CCGs. This compared with 57 CCGs in 2016-17 and 56 CCGs in 2015-16.

The NAO added that as part of their total budget plan, CCGs had consistently spent less than their running costs funding, which had been reduced from £1.35 billion in 2013-14 to £1.21 billion currently. In November 2018, NHS England confirmed that CCGs’ running cost allocation would reduce by a further 20% by 2020-21.

The spending watchdog meanwhile highlighted how CCGs across the country were struggling to attract and retain high-quality leadership. “While 54% of CCGs were assessed by NHS England to have good leadership, issues around recruitment and retention include a reluctance among staff to step up to senior positions because of increased pressure, the uncertain future of CCGs and a lack of access to training and development.”

The report noted how the structure of CCGs was evolving, with mergers, shared senior management teams and increasing joint working. “This is being prompted by factors including wider changes across the NHS, budgetary pressures and as CCGs’ understanding of the most appropriate commissioning structure for their local area develops.”

The trend is expected to continue, which will likely lead to fewer CCGs covering larger populations, the NAO said.

However it warned that there was a risk that working across greater populations would make it more difficult for CCGs to design local health services that were responsive to patients’ needs. “NHS England has allowed CGGs to take the lead in determining their new structures, and CCGs see their future role as being that of a strategic planning organisation, with the more operational activities relating to commissioning being sub-contracted to provider organisations.”

NHS England is expected to set out its vision for commissioning in its long-term plan for the NHS in December 2018. It has said it will step in where CCGs diverge from its vision of effective commissioning, but it has not set out the criteria it will use to determine when to intervene, the NAO noted.

Amyas Morse, the head of the NAO, said: “We have seen almost three decades of change to NHS commissioning. It would be a huge waste if in five years’ time NHS commissioning is undergoing yet another cycle of reorganisation resulting in significant upheaval.

“The current restructuring of CCGs must deliver balanced and effective organisations that can support the long-term aims of the NHS and deliver a much-needed prolonged period of stability.”