How CCGs are being rated by SHAs

More than a dozen clinical commissioning groups have been red-rated.

Dr Kingsland: 'A minimum CCG patient size was never the government's plan.' (Photograph: NTI)
Dr Kingsland: 'A minimum CCG patient size was never the government's plan.' (Photograph: NTI)

Last month, DH commissioning czar Dame Barbara Hakin revealed that the majority of clinical commissioning groups (CCGs) across England have passed the first step towards authorisation.

It has been reported by BMJ Careers that of the 243 emerging groups in England, 62% were rated 'green' by their SHA cluster on their engagement with member practices, geography and patient population, relationship with local authority boundaries and size.

A third were rated as amber and 6% red.

CCGs were required to undergo a risk assessment of their configuration by December 2011 as the first step towards authorisation by the NHS Commissioning Board.

Accountable to clusters
The top 94% are expected to take over commissioning budgets from PCTs in April to allow them to operate in shadow form for a full year before authorisation in 2013. They remain accountable to PCT clusters for those budgets until they are fully authorised.

A high-profile casualty was DH clinical commissioning network lead for England Dr James Kingsland whose CCG (the eight-practice NHS Wirral Alliance, covering 44,000 patients) was red-carded and is now standing firm in the face of pressure to merge.

Dr Kingsland spoke exclusively to GP about the decision. Watch a video of him explaining why he still believes his CCG should not be merged or 'reconfigured'.

Asked whether the government has a specific minimum patient size for CCGs in mind, Dr Kingsland says: 'That was never the government's plan. It was always meant to be self-determined.'

He acknowledges that there is 'some danger' of waning enthusiasm thanks to such stipulations but maintains that the spirit of reforms has not been lost. Dr Kingsland adds: 'Some are very engaged. There are lots of good reports. Others are getting the very different message that they must reconfigure otherwise they won't be authorised. It's interesting when we haven't got a Health Bill introduced into law as yet.'

The optimum CCG size has been the subject of debate for months. In September 2011, Hannah Farrar, NHS London's director of strategy and system management, said all CCGs would have fixed costs common to all statutory bodies, including for audit and governance, and subtracting this from their funding left CCGs in London with an average of £20 per patient, varying between £3 and £23 per patient depending on their size.

Asked what was the lowest population at which safe care was possible, she said: 'If it's less than 100,000 population, you are going to struggle to get the calibre of support needed.'

Ready reckoner for CCGs
The DH was also criticised for producing a ready reckoner for CCGs which defaulted to populations of 300,000. Health secretary Andrew Lansley admitted that the 200,000 average would have been a more appropriate figure. Dame Barbara said 300,000 had been chosen only to present illustrative figures.

Last year, Dr Stewart Findlay, then chairman of Durham Dales CCG, told Mr Lansley his CCG was being pressured to merge. He told him: 'We have one local authority which has decided that it wants one CCG, the clinical senate will have a similar view. We feel it will prevent us from the sort of grouping that is the right way forward.'

The 96,000-patient Durham Dales CCG has indeed since merged to become the 280,000-patient Durham Dales, Easington and Sedgefield shadow CCG.

Dr Findlay, now the merged CCG's Durham Dales locality lead, says the £25 per patient management cap has put CCGs under pressure to merge.

He says: 'It was obvious we wouldn't be authorised if we remained small. I think the only CCGs which will survive small and stand-alone will be those with small unitary local authorities. It's not easy to merge. Other localities may not think the same way as you do.'

But he remains hopeful that the existence of localities like his will enable some degree of local decision-making and budget control.

Ken Spooner, chairman of England's smallest CCG, the red-carded 19,000-patient Red House Group in Hertfordshire, joins Dr Kingsland in standing firm against pressure to merge.

He says: 'We're going to proceed with authorisation and see what happens. We really don't know what will happen because the health secretary has been quoted as saying that CCG size should be determined by what's best for patients and local GPs and so that's the mast to which we are hanging.'

But a smaller-than-average population size has not been a problem for all emerging CCGs. Bassetlaw Commissioning Organisation in Nottinghamshire covers 100,000 patients but received a green rating.

One-size-fits-all is clearly not applicable to emerging CCGs. Mr Lansley may well hope the dwindling number of CCGs does not reach 152 however, the number of PCTs there were when the policy to abolish them began. If it does, the DH opens itself to the accusation that little progress has actually been made after a period of great upheaval.


East of England (number of CCGs = 26)

Best 'Green': Bedfordshire, North East Essex, West Essex and Mid Essex.

Worst 'Three red ratings': Red House and Multi-consortium Thurrock and Basildon.

East Midlands (number of CCGs = 22)

Best 'Green': Leicester City, West Leicestershire, Nottingham City, Nottingham North and East, Nottingham West, Mansfield and Ashfield, Newark and Sherwood, Principia Rushcliffe, Nene Commissioning and MK Commissioning.

Worst 'One red rating': High Peak and Buxton.

West Midlands (number of CCGs = 27)

Best 'Green': South Warwickshire, Dudley, Wolverhampton City, North Staffordshire, Stafford and Surrounds, Stoke on Trent, Bromsgrove and Redditch, Hereford, South Worcestershire, Shropshire, Telford and Wrekin and Wyre Forest.

Worst 'Two red ratings': Nuneaton and Bedworth, Birmingham Inner City Commissioners and Wolverhampton Primary Care.

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