Last year I wrote a blog about the plans in Cheshire to create a single Joint Commissioning Committee (JCC) working across the four Clinical Commissioning Groups in Cheshire (West Cheshire CCG, Vale Royal CCG, South Cheshire CCG and Eastern Cheshire CCG). You can read the blog here and I would recommend that you do.
I’m pleased to say that we have established this committee. It is up and running with representation from all of the four CCGs from a clinical, executive and lay-member perspective. We also have our local authority and public health colleagues in attendance as well as a nursing representative.
We are now turning our attention to the possibility of merging the four CCGs into one.
The question I am being asked is “Why?”
This is a good question. When CCGs were created they were made as Membership organisations, with the local GP practices as the Members. They were (mostly) small and representative of their local area, able to understand the local needs and commission appropriately for them. GPs have good representation on the Governing Body, and easy routes into this to ensure their voice is heard. Surely creating a much larger organisation will risk losing this?
I understand the concerns, but we need to understand why we are suggesting a move to Cheshire-wide Clinical Commissioning.
It is all about the development of Integrated Care.
The one consistent thing we have been working on since the advent of CCGs is integrated care, closer to home, seamlessly managing patients, avoiding them bouncing between services, keeping people out of hospital, developing primary, community and mental health to reduce the need for secondary care intervention. The Holy Grail for CCGs seems to have been trying to achieve this. We have done much to work towards this, but have much we still need to do.
A local Integrated Care Program will hopefully bring about some of this. In its development we will be creating something new that will perform some of the functions of a provider, and some of a commissioner Some of the functions currently undertaken by a CCG will be done in an ICP. This means that we may need less people in the CCG (and more in the ICP) and that the CCG will need to operate very differently to it does now, to allow space for the ICP to develop and perform well.
That’s why we need to consider merging the Cheshire CCGs. To allow us to develop Integrated Care, which is what we believe we need to do to improve things for our patients. This is fundamentally about improving patient care.
Developing ICPs and devolving budgets to them also means that local GPs can continue to work in local care communities, having a voice and a say in how we develop local care.
There is another reason that is specific to the people of Vale Royal and South Cheshire. We have long been working together to develop integrated care around the Central Cheshire area, primarily because most of our patients will use the same local hospital. Recently we have moved to develop two integrated care programs across Cheshire – Cheshire West ICP and Cheshire East ICP. This has split the Central Cheshire work, with Vale Royal aligning with West Cheshire and South Cheshire aligning with Eastern Cheshire. If we are to ensure that local patients get the same ‘offer’ when they present to the same hospital, but from different ICPs, then we need one commissioner to define the outcomes required and commission accordingly. In simple terms a patient from Winsford presenting at Leighton Hospital should get the same care as a patient from Middlewich. (If you are not local, then look at google maps to see what I mean.) One Cheshire Commissioner will help us to do this. There are other examples already happening that we could do with addressing – patients in Winsford or Northwich (within Cheshire West and Chester Local Authority) received different weight management services to patients in Frodsham or Tarporley (also in Cheshire West and Chester).
As well as creating space for ICPs we do want to address the inefficiencies of 4 CCGs across the area – we can commission more effectively and get things right for our population if we do it once.
All of the above explains our ‘Why?’
The ‘How?’ question is next. Our plan is to continue developing the ICP and to gain approval from our GP Memberships to pursue work to bring the CCGs together, creating joint committees, appointing a single Accountable Officer and bringing the executive teams together. If we are to then look to merge by April 2020, then we need to put in an application with NHS England by July 2019. If we can put an executive team in during the current financial year, they can help us to pull all this together.
The ‘How?’ will also inform the ‘What?’ – in other words, what will the final merged CCG and the ICPs look like. We need our Memberships and others to help us with this. GPs are rightly concerned about how they will continue to have a say and a voice – we need to build this into the process and we want to hear from our GPs with regard to any ‘checks’ that need to be in place as we proceed. We need to work on how GPs will be represented, and how they can be sure their voice counts.
Some have asked if this is a ‘done deal’ – absolutely not – if the GPs don’t want a merger, there will not be a merger. Some have asked if we are being told to do this by NHS England – absolutely not – this is our plan and vision.
My final point is a ‘What if…?’ – as in what will happen if we don’t merge. I think this creates problems for us in Central Cheshire as it drives planning into two geographies that are co-terminous with the Local Authorities. This pulls apart our natural local health economy. A single commissioner can set the desired outcomes across both Local Authority areas, and ensure everything is joined up.
We cannot do this without the engagement and involvement of our local GPs who need to feel they are listened to.
It has been about a year since my previous blog about ‘Cheshire’ – maybe next year I’ll be doing another one to let you know how we are progressing.
Dr Jonathan is a GP in Swanlow Surgery in Winsford, Cheshire, and Chair of NHS Vale Royal Clinical Commissioning Group.
Got a question? Find Jonathan on Twitter @DrJonGriffiths