Clinical Commissioning Groups in England serve too many masters

12 Dec 2013

The accountability regime is much more complex than in previous system and has competing agendas, a University of Manchester study has shown.

Dr Kath Checkland
Dr Kath Checkland

Clinical Commissioning Groups, the new family doctor led bodies responsible for commissioning the largest chunk of healthcare in England, are accountable to too many masters with potentially competing agendas, concludes research undertaken by the Policy Research Unit in Commissioning and the Healthcare System and led by The University of Manchester, which was recently published in the online journal BMJ Open.

Clinical Commissioning Groups, or CCGs for short, are membership bodies that came on stream in April this year as part of a major restructuring of health and social care services in England. They replaced primary care trusts (PCTs).
The ostensible aim was to boost the accountability of those responsible for commissioning care for patients while at the same time giving them greater autonomy than that enjoyed by their predecessor organisations.
The authors wanted to take a detailed look at the developing accountability relationships of eight CCGs, because the degree of autonomy they will have, will, to a large extent, depend on these relationships, they say.
Between September 2011 and June 2012, they interviewed 91 people, including family doctors (GPs), managers, and governing body members; carried out 439 hours of observation in many different types of meetings; and analysed a wide range of documents.
CCGs are externally accountable to NHS England (the government); Monitor (the regulator), Health and Wellbeing Boards (public health and social care); the local Health Watch (patients); the public; local medical committees (GP bodies); and the local authority Overview and Scrutiny Committee (public health)
They are also internally accountable to the CCG governing body, member practices and locality groups.
The authors conclude that CCGs are indeed more accountable than PCTs. In fact, they “are at the centre of complex web of accountability relationships, both internal and external,” they say.
Dr Kath Checkland, from the Centre for Primary Care at The University of Manchester who led the research, added: “However, whether this translates into being more responsive, or more easily held to account, remains to be seen.”  
Previous research indicates that complex accountability arrangements tend to generate confusion, “and where organisations are accountable to multiple audiences, the interests of these audiences may differ, generating unintended consequences,” they suggest.
The accountability relationship with NHS England is the only one that is clearly defined, and where sanctions apply, they point out.  “The accountability to other external bodies, such as Health and Wellbeing Boards, is by contrast much weaker,” Dr Checkland adds.
Accountability to the regulator may be enforced by competition law, but it is unclear how this will work in practice, they suggest, while accountability to the public is political and based on “the relatively weak notion of ‘transparency’ with no associated sanctions,”
Based on the responses of the interviewees, they suggest that CCGs may choose to satisfy their public audiences rather than the government. This could mean that they choose to avoid “hard decisions in the face of public opposition,” the authors say.
Internal accountabilities are equally complex, and it is unclear what sanctions would or could be applied to general practices that transgress the rules of the CCG, the authors point out.
Dr Checkland concludes: “This early study raises some important issues and concerns,including the risk that the different bodies to whom CCGs are accountable will have differing (or conflicting) agendas, and the lack of clarity over the operation of sanction regimes.”

Notes for editors

The article appears in BMJ Open 

Title: Accountable to whom, for what? An exploration of the early development of Clinical Commissioning Groups in the English NHS doi 10.1136/bmjopen-2013-003769
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