The challenges of creating the largest CCG in England

Source: NHE March/April 2018

Paul Sherriff, director of organisational development and partnerships at NHS Birmingham and Solihull CCG, discusses some of the challenges with creating the largest clinical commissioning group in England.

Between May and September 2017, the three CCGs in Birmingham and Solihull secured approval to merge and create the largest clinical commissioning group in England after consulting with the public. The merger is now being progressed, with the new NHS Birmingham and Solihull CCG to begin on 1 April.

CCGs are obviously membership bodies; it really couldn’t be estimated highly enough how important GP engagement was in this process. There are 177 GP practices across Birmingham and Solihull, all with varying levels of involvement and ideas about how commissioning could be changed and improved to address the considerable health inequalities we have in the area, and ultimately improve outcomes for our patients. The possibility of a merger was discussed for some time before the official process started, so awareness amongst GPs was high.

Once pace started to gather, we had to act quickly to engage local clinical leaders in the reality that this could now really happen. We also had to think about how we could explain this possibility to our most important partners – our patients – and what it would mean to them.

It was felt that a single commissioning organisation for Birmingham and Solihull would provide commissioners with a stronger voice in the region, and assist in developing integrated commissioning arrangements. For patients, it would also reduce variation in services.

It may be a cliché in the NHS, but for all those involved in pushing forward with the change in Birmingham and Solihull, the greatest challenge was culture. Bringing together three different organisational cultures, and developing a new and shared one for the future, was a challenge. The way in which clinical engagement had been structured in each CCG was also different, so there had to be an honest conversation early on that acknowledged that none of the existing models were going to work on this new scale and that something new was needed.

Briefing our statutory and other key stakeholders well in advance of the public consultation as part of pre-consultation engagement was also really important. Key people were aware that a potential change was on the horizon, and this helped us all manage the process more effectively. We cannot emphasise enough how important it was to engage local authority partners, especially the health overview and scrutiny committees.

One of the main challenges during the pre-consultation and consultation phases from stakeholders was concern about the loss of identity for Solihull, and loss of recognition for distinct communities in Birmingham, as well as concerns that Solihull CCG’s documented financial position at the time would mean that Birmingham’s resources might be used to support Solihull. I can honestly say the most important thing in addressing them was having a strong and clear response acknowledging, where appropriate, that we didn’t have all of the answers.

We were also concerned about a general lack of interest in the public consultation. We were wrong.

By having a robust consultation plan, and using the CCGs’ communications and engagement channels, we got a solid number of quality responses from individuals and organisations, from right across the patch.

Governance is culture

The main challenge in terms of governance was the CCG constitution, but not necessarily writing it. Governance is culture. It describes how you do the organisation’s business, how you operate. Having three constitutions and needing to write a new one brought all the cultural differences to a head; there were fundamental variations in the way the three CCGs did things.

Ironically, one similarity that all three CCGs had was that they all held member councils/forums. This turned out to be the one thing that we couldn’t take forward, as it would have meant taking too much of the workforce out of the system at one time. A new model of clinical engagement has since been developed and endorsed by the governing body GP leads.

We knew that setting up a new organisation of this size would mean that things would change quickly; we were very conscious that the constitution could become out of date. With this in mind, we took a fairly unique approach to have a CCG handbook as an ‘easy read’ companion to the constitution.

A strong stance on conflicts of interest was taken. We decided that any individual with a significant responsibility in a provider organisation could not be a clinical commissioning lead or have a GP position on the governing body. We were absolutely clear from the start that conflicts of interest would be dealt with and managed openly and transparently.

A national first

The other interesting challenge, which we probably did not anticipate, was that this whole process would be a learning curve for NHS England, too. There has not been a merger of CCGs on this scale. Whilst we were going through the merger application process, there were unknowns on both sides. We were operating at pace whilst assuring NHS England, involving our GP membership, and ensuring public transparency, involvement and accountability. And, of course, our business as usual activity.

We have learned so much from this process, and as a result of this there will be some new national procedures and frameworks for CCG mergers. We have also developed a more positive relationship with our stakeholders, both old and new.

Here are my five tips for CCGs looking to embark on a fully functional merger:

  1. Establish a project team, which involves representation from all the key functions within your organisation, and your local NHSE DCO team;
  2. Invest in a stakeholder analysis and discuss your ideas, as early as possible, with your key influencers;
  3. Keep an issues log from the start, to ensure you capture the concerns and issues people raise. Develop, and share, clear responses to the concerns raised;
  4. Look to expert advice where you need it, for example legal – investing in it early on can save problems further down the line;
  5. Do not underestimate the sheer amount of time, resource and effort involved. In particular, one-to-one stakeholder and public consultation meetings are a very important investment.




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