Published by Alexander Hitchcock on 1 April 2016
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7 April 2016
On 1 April, Manchester took control of its £6 billion annual health and social-care budget, in what Simon Stevens has called potentially “the greatest act of devolution there has ever been in the history of the NHS.” The responsibility for designing and delivering services to meet Manchester’s care needs has moved from Whitehall to 37 local bodies, including 10 councils, 12 clinical commissioning groups (CCGs), and 15 NHS trusts and foundation trusts.
At the heart of this transition lies a crucial aim: the integration of services to meet the needs of Greater Manchester’s 2.8 million people. As Bury council explained, the aim is to create one body to “ensure that joined up commissioning of health, social care and wellbeing services is undertaken, through the whole pathway”. Manchester hopes this approach will allow it to meet its challenge to find £2 billion of savings by 2021, while improving wellbeing for its people.
This gets to the crux of an issue that has plagued the NHS: a fragmented funding framework, which drives a siloed approach to healthcare. Funding for general practice is separate from public health, which undermines GPs’ incentives to focus on prevention of poor health. The Health Select Committee has previously warned that “separate [health and social care] systems are inefficient and lead to poorer outcomes for older people.” When asked to list the barriers to dealing with financial problems, the conflicting priorities of different national bodies was the most commonly cited response from CCG leaders.
Outside of Manchester, an attempted solution has been to delegate more responsibilities to CCGs – to turn them into organisations responsible for commissioning the whole care needs of populations. Today’s 209 CCGs were created in 2012 to commission secondary care services, but since 2015 have been able to commission primary care. A majority of CCGs now undertake this role; all are expected to do so by 2017-18.
Yet, it is not clear that CCGs are best-placed to fulfil a more extensive commissioning function – particularly for primary care. Large primary-care providers are already outgrowing their CCG: in 2015, Lakeside Healthcare, which cares for 100,000 people, was denied its bid to switch CCG as it would have made its current CCG unviable. In Staffordshire, three CCGs, with a £600 million budget, covering 500,000 people, are planning to merge to manage financial risk – suggesting CCGs are currently too small to manage larger contracts.
The direction of travel is towards pooling budgets to deliver integrated care. The Government has pledged to integrate health and social care services by 2020, with local commissioners tasked with developing plans to achieve this. It is welcome that commissioners are being given the freedom to design plans, but the Government should articulate a vision for commissioning integrated care across all areas of the NHS. Without this, pockets of change, such as in Manchester, will continue to make headlines, but little progress will be made across the country.
Alexander Hitchcock, Researcher, Reform