Cllr Samer Bagaeen represents Hove Park on Brighton and Hove Council. He is a Visiting Professor of Planning at the Institute of Urban Economy, Universidad Esan, in Lima, Peru.
We must get a better understanding of how our health funding is put to use to serve the residents of our town and cities and rural areas. The key word is commissioning. This is the process by which health and care services are planned, purchased and monitored. Curiously, they are planned, purchased, and monitored by more or less the same people who plan, commission and purchase! This range of activities includes, obviously, the following: assessing needs, planning services, procuring services, and monitoring quality.
The concept of commissioning was introduced into the NHS in the early 1990s, when reforms separated the purchasing of services from their delivery, creating some kind of an ‘internal market’.
The argument was that forcing providers to compete for resources would encourage greater efficiency, responsiveness, and innovation. It did not and these arrangements have continued to evolve over time with several changes to the structure and remit of the organisations that commission care. The current arrangements were introduced by the Health and Social Care Act 2012.
In budget terms, and this is where some local politicians get the wrong end of the stick, the largest part of the NHS England’s budget is allocated to what we know as clinical commissioning groups, or CCGs, or groups of local GPs practices. In 2018/19, these CCGs spent £85.4 billion out of the £112.7 billion that NHS England spent on the day-to-day running of the health service. This money was not theirs to start with, it was taken off the local government funding settlement.
When CCGs were first established in 2013, there were 211 of them. Over time though, their number has changed and continues to do so. There have, for example, been some 10 formal mergers, reducing their number to 191 (April 2019) with more proposed for 2020 had it not been that the pandemic, a double edged sword, got in the way.
The CCGs are responsible for commissioning most NHS services including urgent and emergency care, acute care, mental health services, and community services. These groups of local GP practices are managed through governing bodies that include, surprise surprise, GPs, other clinicians such as nurses and secondary care consultants, patient representatives, general managers from the NHS and local authority representatives.
One might think the CCGs are therefore not very democratic or accountable given the huge budgets they manage. NHS England’s total spending on direct commissioning in 2018/19 was £24.5 billion and most of their commissioning function is delivered through regional teams. For where I sit in the South East, NHS England and NHS Improvement South East are one of seven regional teams, covering the counties of Kent, Surrey, Sussex, Oxfordshire, Berkshire, Buckinghamshire, Hampshire and the Isle of Wight.
Sitting across the table from the CCGs are the Local Authorities who are responsible for commissioning publicly funded social care services. This includes services to people in their own care homes as well as residential care services. In 2017/18, total expenditure on adult social care by local authorities was £21.3 billion.
Since 2013, local authorities have also been responsible for commissioning many public health services including sexual health services, health visitors, school nursing and addiction services, and in 2019/20, the public health grant to local authorities was ring fenced at £3.1 billion.
Within local authorities, health and wellbeing boards, where I sit for example, are formal committees that bring together local authority and NHS representatives to collaborate. One of their responsibilities is carrying out joint needs assessments with CCGs and developing joint health and wellbeing strategies for the local population.
In Brighton & Hove, a resident, John Kapp, who’s a keen health observer and one of the few residents always there with questions to members of the Health and Wellbeing Board, recently exposed what he called ‘Fake news’ promoted by the Leader of Brighton and Hove City Council who wrote in the local newspaper, the Argus:
“Councils have lost one in two pounds in real terms funding since Tory cuts began in 2010. The National Audit Office report that in Brighton and Hove the amount of government funding has fallen by a staggering 53 per cent in real terms.”
This is fake, John argued, because it ignored the history and context described here. It took, he said, no account of the transfer from 2013 onwards of the health budget to the 219 CCGs. The amount devolved in England is now about £90 billion per annum, he notes, of which the Brighton and Hove CCG receives some £470 million per annum. Together with the Brighton and Hove City Council total annual budget of £760 million, this makes the total devolved for local decision making £1,230m per annum.
Should this money, John asks, be devolved to the Brighton and Hove Health and Wellbeing Board in order for locally elected democratic representatives to be able to call the CCG to account for getting best value, instead of regarding it a ‘partnership’ body? This is probably the only way to integrate health and social care by filling the apparent, but clear, democratic deficit.
Some local authorities have inched towards this and transferred some commissioning responsibilities to CCGs but also vice versa, and some areas have made joint appointments across the two organisations – for example, in Tameside and Glossop, the CCG accountable officer is also the chief executive of the local authority. Systems integration at its very best!
In some other places across England, devolution is also being used to support system-wide approaches to commissioning and our newly created National Preparedness Commission in England would do well to take off the blinkers and take notice of this. The most prominent example of this is Greater Manchester, where CCGs, local authorities and other local bodies have come together to take responsibility for the entire local health and care budget as opposed to the business as usual, you do your thing and I’ll do mine. These arrangements were enacted through an agreement between the Greater Manchester Combined Authority, NHS England and CCGs.
A key ask here is that service delivery after the pandemic must change so that integrated health provision is, well, more integrated. And more importantly, more accountable.
In Wigan, under the banner of ‘Healthier Wigan’, the NHS, the Council and other partners in Wigan borough are working together in the Healthier Wigan Partnership to make health and social care services better for residents. Wigan Council and NHS Wigan Borough CCG are continuing to change the way they commission local health and care services by working together, and from April 2019, began to commission local services as if we are one organisation. One good vehicle for this has been the appointment of a single Council/CCG Director of Finance. There is also an Integrated Commissioning Committee being the formal committee for delivering this commitment to integration. It is a joint committee between Wigan Borough CCG and Wigan Council. Members of the committee are from the CCG’s Governing Body and Council’s Cabinet.
One of the many questions we therefore need to ask is if this arrangement provides better, more integrated services to residents, why is it not the norm?