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GPs buried under trusts' workload dump

CCG mergers ‘reduce the voice’ of practices, warns LMC

The move towards larger integrated organisations will make CCGs more distant from practices and will reduce support for PCNs, an LMC has warned. 

Essex LMCs expressed concerns over national proposals to reduce the number of CCGs in England so they match the number of Integrated Care Systems (ICSs). They intend to ballot all Essex practices as to whether they are in favour of CCG mergers before Christmas. 

The LMC said any 'enforced hasty top-down change' will result in GP practices having less input in local decisions and prevent the successful delivery of the NHS long-term plan. 

It comes after CCGs in mid and south Essex announced in September their intention to consider to start the application process to merge their five CCGs into one by April 2021.  

As part of the long-term plan, ICSs will cover the country by 2021 - which will see one CCG per ICS area - meaning there will be fewer commissioners who will become responsible for larger geographical areas.

Following the announcement, CCG mergers have increased, while more recently four CCGs in Cheshire revealed their plans to merge in April 2020

In an email sent last week to GP practices, and seen by Pulse, Essex LMCs chief executive Dr Brian Balmer said reducing the number of CCGs will 'disadvantage bottom-up integration via PCNs'.

He said: 'You may be aware that NHS England plans to merge CCGs into larger Sustainability and Transformation Partnership (STP) wide organisations by April 2021. This plan rather neglects the fact that CCGs are member organisations and that such a change would involve an agreed change in constitutions, but NHS England has stated that mergers will only occur where they have the support of practices.

'The merger plans are part of a move towards ICS which form part of the delivery of the NHS long-term plan. The Essex LMCs believe that these changes will have a profound influence on practices and the development of primary care, and that practices must be properly consulted prior to such plans becoming inevitable due to reductions in staffing and management changes within CCGs.'

The LMCs pointed out that NHS England proposals and any 'enforced hasty top-down change' come with a string of problems.

These include:

  • Larger CCGs will be more distant from practices and reduce their voice;
  • A move to more remote CCGs will disadvantage bottom-up integration via PCNs;
  • CCG managers will be less able to support PCNs during 18 months of CCG merger and cost-cutting plans;
  • Too rapid top-down integration risks the successful delivery of the long-term plan;
  • Fewer, larger CCGs will not strengthen commissioning and control secondary care costs as the integrated system will be dependent on, and built around, large acute trusts.

The LMCs will hold a vote with all practices in Essex before Christmas to 'clarify the support for the NHS England plans'.

Dr Balmer said: 'We will send information to practices at that time and will attempt to give a balanced view of the proposals but at present, we are struggling to see any benefits to primary care or patient health and welfare to be gained from this change.'

Earlier this year, the Public Accounts Committee, which has been scrutinising CCG performance, said GPs should be involved in CCG decisions, as services are increasingly commissioned across larger areas and commissioners risk 'losing touch' with their local population. 

In July, the BMA wrote to NHS England demanding that mergers only go ahead after receiving approval from their member practice, after warning that current guidance does not allow GP practices to have sufficient input in CCG merger proposals. 

And last month, North Staffordshire LMC urged GP members to block the merger of their CCG with five others over budget fears.

Readers' comments (4)

  • For once our voting has been by hidden ballot, a show of hands would have most likely given a total rejection of the concept of amalgamation of CCGs. ~When it is convenient it is a show of hands, when not - a ballot which can't be verified. Bravo CCG. In the build up to the vote we had only one private provider arguing for while everybody was against, the result however, was what it was.

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  • The GPs never really had a voice anyway. The CCGs just pretend at listening.

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  • When my local CCGs merged, I strongly argued against and said that I wanted to vote against. However, vote was one vote per practice so no individual voice. CCG instructed the few that put their hands up that they must vote yes as there was no alternative. Usual CCG tactics of token show of hands to rubber stamp a done deal. CCG board stay on long past their ‘elected’ terms. Results of votes never published (always result with no honesty about number of votes cast for or against). It’s apparently ‘better for everyone’ that those with the power hang on to it.

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  • Vinci Ho

    (1) Once again , there is always a risk of an ‘one size fits all’ argument as far as merging-protagonists and antagonists are concerned. Yes, ‘more opportunities to share resources and expertise’ is sound , enticing and worth pondering.
    Question is , have you really got so much ‘surplus’ to be shared from the outset , putting these individual CCGs together under one roof in each case ? If only nine lids are currently available to cover ten teacups( hence , one short) , it does not make sense to gather eighteenths lids together to cover twenty teacups because it will become two short instead .
    (2)The geographical spread in every region of concern(with how many CCGs within) is a valid point for debates . Clearly , too many practices away from the ‘centre’ means less practical representation. CCGs with rural practices are likely to be disadvantaged if the boundary of the CCG is being pushed further outwards . Nevertheless, we all know the demographic (and hence, epidemiological)variation in health inequalities and diseases will accentuate as the ‘region’ is getting bigger and bigger . Financially, it may be more convenient for NHS England to fund by writing ‘one single cheque instead of many’ . The truth is , we all know that this always offers NHSE advantages to impose more draconian measures effectively and efficiently.
    (3)The relationship between CCGs and PCNs is already rather extraordinary. CCGs are constantly under the cloud of NHS England to save so many millions of pound every year while the new kid on the block , aka PCNs are supposed to be fed directly by NHSE( whether the feeding ‘enough’ is another matter ) . As I wrote before , CCGs and PCNs had virtually become a caricature to each other as they are both formed by GP membership fundamentally. Will today’s PCNs become tomorrow’s CCGs ? History will be the judge .
    (4)My gut feeling is that the voices of GPs within currently existing CCGs have already been diluted by layers of top-down bureaucracy laid down by the hierarchy in the system . When you merge more CCGs together , the caveat of further dilution is only logically apparent. And it is quite right to say the bigger providers , hence , players , are the acute trusts in an integrated care system (ICS) . Everybody (every provider) has its own needs . It is always about individual interests superseding ‘common interests’ .If one ICS means one CCG , the acute trusts clearly want to be on front foot to run the show . As a ‘reluctant’ clinical director of a small PCN , I can already smell dissatisfaction of some providers against ‘dominant’ providers within the same system . The bigger the system goes , the more friction can potentially arrive .
    (5) The bigger the better , I will always express my scepticism (rather than detesting immediately) as much as like remaining as a PCN-sceptic . I always believe in Trilemma Theory : Integration , sovereignty and democracy, you can only have two out of three but never three together at the same time .
    Brexit , Catalonia , Hong Kong , Kashmir etc . What a wonderful world 🤓😈

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