Commission Impossible?
By Lucy Fisher. 10th August 2016

It’s been an emotional few months for the NHS. First there was the EU referendum – its name plastered over buses and billboards, while politicians wrestled over whether leaving the EU would be its making (citing £350 million more a week to invest in the NHS) or its undoing (warning over 5% of the NHS workforce’s employment would be at risk). Then there was Theresa May’s cabinet reshuffle. While rumours flew that Jeremy Hunt had been unseated, he remained as Secretary of State for Health, and three new ministers were allocated to the Department to serve beneath him. This all took place amid much wider ongoing discussions about funding shortages across the NHS.

Fast forward to a week after the EU referendum and, gaining fewer column inches but no less worthy of them, the NHS reset day took place, with an update on NHS performance and finances. As part of this update on performance, NHS England announced that 26 out of 211 Clinical Commissioning Groups (CCGs, responsible for delivering NHS services at the local level) had been rated ‘inadequate’. A further 91 had received the rating ‘requires improvement’, while nine CCGs were placed in special measures.

That over half of the 211 CCGs in England are rated either inadequate or require improvement paints a picture of a troubled commissioning landscape, and one in which the average CCG has not been able to meet the expected performance standards. The complexity and challenges within commissioning are also illustrated by exclusive ComRes research conducted among CCG representatives, which shows mixed views around their perceived capacity to deliver on clinical and financial targets. The financial outlook in particular is not optimistic, with many CCG representatives unsure of being able to hit the financial performance targets they have agreed with NHS England (their ‘control total’). Around half of CCGs say they are not confident they will achieve their control total (48%), while the other half say they are confident (48%).

The fact that half of CCGs think they will not achieve their control total reflects significant financial challenges for CCGs and suggests there is more at play behind the figures. This is particularly true given that, despite the financial challenges they face, CCGs appear positive about commissioning more broadly, and their role within it. Two thirds agree that their CCG is sufficiently empowered to commission services that local patients really need (67%).

Despite this, CCGs perceive their finances to be having a substantial impact on their ability to meet those needs. More than three in four disagree that their CCG has the financial resources to deliver what local patients expect (76%), with as many as two in five strongly disagreeing this is the case (38%). The efforts required to meet financial targets, then, appear to be impacting CCGs’ ability to deliver on other parts of their remit, as they are faced with one of two options – overspend and deal with the consequences, or fail to meet the demands of local populations.

CCGs pollwatch graphic

It is widely acknowledged that, for a number of reasons including an ageing population, demand for NHS services is steadily increasing. With half of CCG representatives disagreeing that their local area is in a better position to deliver services to patients than it was 12 months ago (52%), CCGs do not appear convinced that the resolution to this conflict is around the corner. In an ideal world, meeting local demand and hitting financial targets would not be mutually exclusive. But there appears to be a tension for CCG representatives in being able to do this. And alongside the perception that their ability to deliver is getting worse, the majority of CCG representatives do not feel that their needs are understood. Only around one in ten representatives say that the Secretary of State for Health and his ministerial team have understood the needs of local commissioners (9%) or listened to local commissioners (10%) over the last 12 months.

The challenge around NHS financing is ongoing. This is particularly true as we wait to see the impact of Brexit on the UK economy, as this will no doubt have consequences for the NHS. While the NHS budget was protected in the last spending review, it remains to be seen whether the Department will be afforded the same luxury when the Autumn Statement comes around. Even if more funding is made available, commissioning will have to compete with other elements of the system to receive its share. If NHS finances are unlikely to improve in the short-term, the challenges that commissioners face are likely to continue. In order for their outlook to improve, CCGs will need to feel empowered to continue delivering positive outcomes to their patients. In the current environment, with so few feeling understood or listened to by their leadership, it is difficult to see this changing.