Clinical commissioning group
Clinical commissioning groups (CCGs) are NHS organisations set up by the Health and Social Care Act 2012 to organise the delivery of NHS services in England. The announcement that GPs would take over this commissioning role was made in the 2010 White Paper, "Equity and Excellence: Liberating the NHS". This was part of the Government's advertised desire to create a clinically-driven commissioning system that was more sensitive to the needs of patients. The 2010 White Paper became law under the Health and Social Care Act 2012 in March 2012. At the end of March 2013 there were 211 CCGs.
To a certain extent they replaced primary care trusts (PCTs), though some of the staff and responsibilities moved to Local Authority Public Health teams when PCTs ceased to exist in April 2013. Services directly provided by PCTs were reorganised through the Transforming Community Services programme.
Structure and membership
CCGs are clinically-led groups that include all of the GP groups in their geographical area. The aim of this is to give GPs and other clinicians the power to influence commissioning decisions for their patients.
Each CCG has a constitution and is run by its governing body. Each has to have an accountable officer responsible for the CCG's duties, functions, finance and governance. Most CCGs initially appointed former PCT managers to these posts. Only a quarter of accountable officers were GPs in October 2014, but 80% of CCG Chairs were GPs. Only half of GP practices said they felt involved in CCG decision making processes. The Health and Social Care Act 2012 provides that the areas specified in the constitutions of clinical commissioning groups together cover the whole of England, and do not coincide or overlap. Each CCG is responsible for persons who are provided with primary medical services by a member of the group, and persons who usually reside in the group's area and are not provided with primary medical services by a member of any clinical commissioning group.
E-reward, an online pay research service, analysed the pay of more than 2,500 managers at the 211 CCGs in England in 2015. They reported that 56% of 225 top executives – chief officers and chief finance officers – were paying themselves more than the salary range recommended by NHS England of £95,000 to £125,000 a year.
Unite the Union surveyed the 3,392 CCG board members in 2015 and reported that 513 were directors of private healthcare companies: 140 owned such businesses and 105 carried out external work for them. More than 400 CCG board members were shareholders in such companies. The King's Fund and the Nuffield Trust ran a survey of GPs in six areas of England in 2016 and found that more than 70% were at least "somewhat" engaged with the work of their CCG, though only 20% of those without a formal role in their CCG said they could influence the work of their CCG if they chose to.
211 groups were established in 2013 and there was resistance to any proposals for mergers between groups although Gateshead CCG, Newcastle North & East CCG and Newcastle West CCG merged on 1 April 2015. During 2016 it appeared that further mergers would be permitted and an official procedure was published in November 2016 by NHS England. During 2017 further proposals for merger appeared. 83 CCGs were sharing chief officers in March 2017, which may be a precursor to merger. If all those led to merger there would be 174 groups. During 2017 mergers between CCGs began, having previously been forbidden. GPs in Staffordshire submitted a vote of no confidence in their local CCGs in protest against a proposed merger. The merger between Liverpool, South Sefton and Southport and Formby CCGs was stopped while an investigation into Liverpool CCG's governance and management of conflicts of interest was carried out, leading to the resignation of several of its leaders. There were similar investigations in Hackney and Crawley.
As at 1 April 2018, the largest CCG in England was created following the merger of NHS Birmingham CrossCity, Birmingham South Central and Solihull CCGs. The newly formed NHS Birmingham and Solihull CCG became responsible for commissioning services for over 1.3 million patients.
Relationship with local councils
In October 2017, it was announced that Brighton and Hove Clinical Commissioning Group was to merge some services with those provided by Brighton and Hove City Council, via a Health and Social Care Integration Board. The board, commencing work in April 2018 and culminating in full service provision a year later, is intended to prevent the duplication of work and streamline provision of health and social care within the city. In Greater Manchester the 10 CCGs are in various stages of establishing a “single commissioning function” with their council.
CCGs operate by commissioning (or buying) healthcare services including:
- Elective hospital care
- Rehabilitation care
- Urgent and emergency care
- Most community health services
- Mental health and learning disability services
Clinical commissioning groups are supposed to work with patients and healthcare professionals and in partnership with local communities and local authorities. On their governing body, each Group has, in addition to GPs, at least one registered nurse and a doctor who is a secondary care specialist. Clinical commissioning groups are responsible for arranging emergency and urgent care services within their boundaries, and for commissioning services for any unregistered patients who live in their area. All GP practices must belong to a clinical commissioning group. The area of the CCG must all be within one top-tier local authority. As originally established CCGs did not have any responsibility for Primary Care which was commissioned and managed by NHS England. In November 2014 CCGs were invited to become co-commissioners of primary care in their area. They would be responsible for the performance management and budgets of their member GP practices, including managing complaints about practices and GPs. 63 will take on fully delegated responsibility in April 2015 and 87 which will begin "joint commissioning", which involves less responsibility.
Tower Hamlets Clinical Commissioning Group, which is chaired by Sam Everington, was awarded Clinical Commissioning Group of the year by the Health Service Journal in November 2014. The judges praised the group's "strong leadership, especially around clinical leadership, while retaining patient focus."
A study conducted by the Open University and University College London in May 2015 found that clinical leaders "seemed to be more willing to challenge or ignore diktats and messages from above, and to encourage their managerial colleagues to do the same". Prof Martin Marshall said clinical leaders were more "focused on outcomes and less interested in processes. They don't really mind how they do things as long as they feel they're having an impact" Having the option of returning to full-time clinical practice meant that clinicians felt a "degree of freedom in what they say and do".
In April 2018 in a dispute brought by City of Wolverhampton Council against Shropshire and South Worcestershire CCGs over their failure to meet the continuing healthcare costs for a patient with learning disabilities Mr Justice Garnham ruled that a CCG cannot pay for treatment of a patient registered with a general practitioner outside their area.
£74.2 billion was distributed among the 195 CCGs in England in 2018/19 This is equivalent to £1,254 per registered patient. The funding formula gives more money to CCGs with elderly populations, in urban areas, or in more deprived areas. The highest allocation per patient was £1,645 for Knowsley and the lowest £1,040 for Oxfordshire. Funding per head has increased in real terms by 2% a year between 2013/14 and 2018/19. 
The Centre for Health and the Public Interest estimated in 2015 that there were about 53,000 contracts between the NHS in England and the private sector, including contracts for primary care services of which the 211 CCGs currently hold 15,000 with an annual value of about £9.3bn in 2013–14. They sent Freedom of Information requests to all 211 CCGs, seeking information about how they monitor contracts with private providers and concluded that CCGs failed to manage contracts with private providers effectively.
According to Christian Mazzi, head of health at Bain & Company, in September 2015 70% of CCGs had failed to monitor their private sector contracts or enforce quality standards. 12% had not carried out any visits to private providers, but 60% could not say if they had done so.
A survey of CCGs by the Health Service Journal in April 2015 found that more than a third were planning to save money by restricting access to services, particularly on "procedures of limited effectiveness", podiatry, IVF, and limiting access to procedures based on aspects of a patient's health, for example whether they smoke or are obese, which can affect outcomes. A similar survey by the GP magazine Pulse, in July 2015, found that many CCGs were planning to restrict access to routine care in various ways.
25 Commissioning Support Units were established in April 2013 by NHS England to provide a variety of support functions, largely staffed by former employees of the Primary Care Trusts. All CCGs were told that they must procure support services by a tender process by April 2015. The first tender, by South Lincolnshire and South West Lincolnshire CCGs was won by OptumHealth with a value of £3 million a year for 3 years. By 2017 only 8 were still in existence.
Initially the commissioning of primary care was done by NHS England. A delegated commissioning model was tried from 2015 and in 2017 it was proposed that most CCGs should take responsibility for GP contracts, as the early adopters had done well and it was "critical to local sustainability and transformation planning". They will also be able to establish new practices, approve mergers and manage 'discretionary' payments.
Incentives and referrals
It was reported in September 2015 that at least 9 CCGs had set up "ethically questionable" incentive schemes to persuade GPs to reduce referrals for new outpatient attendances, follow-ups, A&E attendances and emergency admissions with payments per practice of up to £11,000. Dr Chaand Nagpaul, of the British Medical Association, condemned them as "a financial contaminant" to patient-doctor trust. The General Medical Council guidance, Financial and commercial arrangements and conflicts of interest provides that a doctor should " not allow any interests you have to affect the way you prescribe for, treat, refer or commission services for patients" but the council accepted that "Finance and other incentives can be an effective way of driving improvements in healthcare."
In September a survey by Health Service Journal showed that 34 of 188 CCGs who responded to the survey had restricted access to some services. Restrictions were usually introduced by a number of CCGs acting together across an area. Nottinghamshire CCGs had restricted access to surgery for sleep apnoea and hysterectomy for heavy menstrual bleeding, fat grafts, hair depilation, earlobe repair, and chin, cheek or collagen implants.
See also Health care rationing.
All CCGs had to go through an authorisation process. There were four waves of authorisation between July and December 2012.
In 2014 NHS England investigated Wirral Clinical Commissioning Group after Birkenhead MP Frank Field raised concerns about it. They found that the chair and chief clinical officer "did not demonstrate the necessary close working agreement" about what needed to change within the CCG. There were also questions about the relationship senior leaders had with Arrowe Park Hospital. After the report was published Field repeated his calls for the senior officers to stand aside while a new constitution is made for the governance of the group.
In October 2014 it was reported that NHS England were considering a special measures regime for CCGs in difficulties, of which there were said to be about a dozen. Under the current assurance framework, CCGs are rated as "assured", "assured with support" or "not assured". Only Barnet CCG has been rated "not assured". Guidance issued in August 2015 provides that if CCGs which have been in special measures for more than a year NHS England can "trigger changes in the management, governance or structure of the CCG's responsibilities, with the potential for other CCGs or relevant bodies to take over aspects of the local commissioner's responsibilities". None have yet been placed in special measures.
Shropshire Clinical Commissioning Group was put in special measures in November 2015 after its financial position deteriorated. It expects an in-year deficit of £10.6m for 2015/6. 23 CCGs were rated inadequate by NHS England for 2016-17. In September 2017 5 were given legal directions and two, Lewisham and Greenwich, were ordered to "cease to exercise its acute commissioning functions, including the contract with Lewisham and Greenwich NHS Trust" until April 2019.
Bristol CCG were subject to a legal challenge from a local pressure group, Protect Our NHS, who claimed that their processes for involving patients and the public in their decisions were inadequate. A judicial review was withdrawn in June 2014 after the CCG agreed to amend its patient and public involvement strategy and other documents.
- Category:Healthcare in England by county for local commissioning issues
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