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Healthwatch raises concerns about new ‘Super-CCGs’

NHS Clinical Commissioners has rejected criticisms from Healthwatch and MPs that new ‘super-CCGs’ are making sweeping changes to care in their areas with too little accountability or oversight, saying “there is no need for any further legislation or top-down mandatory requirements”.

These clusters of CCGs have been active all over in England, including in Greater Manchester, North Yorkshire and North West London, for example, in making decisions about care at a regional level. But Healthwatch England says they are circumventing local scrutiny and accountability measures, as they sometimes fail to engage with the public, are not accountable to local democratic oversight and often hold meetings in private.

In North Yorkshire in particular it seems that these new groups have made little effort to inform the public about how decisions to do with their care are being made. Four CCGs in the area have combined to create the Partnership Commissioning Unit, which is responsible for commissioning many community services including mental health, children and family services, continuing care and adult safeguarding. However, the local Healthwatch only became aware of the PCU by accident, when the local Healthwatch co-ordinator, David Ita, ended up sitting next to the PCU director, Janet Probert, at a health and wellbeing board meeting.

Ita told NHE: “At a meeting in May, it just so happened I was sat next to a lady who happened to be the director of the PCU. When she said her name it rang a bell, and I asked, ‘I’ve heard about you, what do you do?’ and she told me. Then she said it would be good for us to have a meeting.”

He did say that since then, he has had good engagement with the PCU, including several meetings between the two organisations to discuss how to best work together.

Things have not been quite so cordial in Greater Manchester, where the 12 CCGs in the conurbation have formed a ‘committee-in-common’ (CiC) to run Healthier Together, a major review of all healthcare services in the area.

The CiC has been operating since February 2012, in shadow form until April 2013. Healthwatch says it has already made decisions on 100 clinical standards for A&E, acute medicine and general surgery, without public involvement.

‘The CCGs don’t understand what Healthwatch’s role is’

The local Healthwatch groups in Grater Manchester have attempted to engage with the CiC and attend meetings but have met resistance. Eventually, the CiC decided to allow some public engagement and split its meetings into two parts, the second of which would be open to the public. But Healthwatch Bolton chair Jack Firth has attended several ‘part twos’ of meetings, and said that all the decisions seem to have already been made in part one.

“The CCGs and CiC in Greater Manchester just don’t understand what Healthwatch’s role is,” he said. “They invited us to some meetings that were public, where they said a lot of people could attend. We did attend but they were not about the strategy, as all that was done by the clinical senates, which we never got an invitation too. So the whole process has been made up by those doing it in secrecy.”

In response to the criticisms from Healthwatch, a spokesperson for Healthier Together told NHE that the 12 Greater Manchester CCGs inherited Healthier Together from the 10 former PCTs in the area and that when the decision was made to take the project on, the CCGs sought legal advice on the best way to do so. They also recruited an independent chair for the CiC and set up an external reference group to represent the voice of patient groups.

“We do appreciate that some groups do hold very strong views about the proposals in relation to their local hospital services,” the spokesperson continued. “It is clear, however, that there has been substantial engagement activity regarding the Healthier Together programme over the last 18 months or so. As well as each local Healthwatch being entitled to send a representative to the External Reference Group which meets monthly, numerous individual meetings have been held with local groups, as well as a range of other stakeholder events and meetings that Healthwatch organisations have been invited to and attended. This is on top of any engagement each Healthwatch may have had with their local CCG.”

CCG reform in Parliament

But Healthwatch England says its experience in dealing with Greater Manchester and North Yorkshire has caused it great concern, especially as the Draft Legislative Reform CCG Order 2014, which will make it easier for CCGs to form joint committees, is currently making its way through Parliament.

The watchdog has written several letters to health secretary Jeremy Hunt to raise concerns. Anna Bradley, chair of Healthwatch England, is calling for a mandatory seat for local Healthwatch on any joint committee; a duty on all lead CCGs to have due regard for existing local priorities and plans; and to ensure all CCGs sign up to act within existing local accountability mechanisms, even if it means being held to account by a health and wellbeing board outside of their jurisdiction.

NHS Clinical Commissioners, which represents the CCGs, says the mechanisms already in place are enough to ensure transparency and accountability. Its director, Julie Wood, cited the five domains of statutory responsibilities that CCGs have, the second of which addresses whether the public and patients are actively engaged and involved. In particular it states: “Continuing to demonstrate delivery against this assurance domain, a CCG will have transparent arrangements in place to feed patient and public insights into CCG decision making, including evidence from local Healthwatch, patient feedback, complaints and concerns”.

Wood told NHE: “We would agree with the secretary of state that CCGs’ statutory responsibility to ensure they have strong transparent and accountable patient and population engagement in their plans, through Healthwatch and local CCG mechanisms are already in place, and there is no need for any further legislation or top-down mandatory requirements of CCGs.”

Concerns were raised in Parliament on 9 September when the Commons debated the Draft Legislative Reform.

Shadow minister for care and reform, Liz Kendall MP, raised many of Healthwatch’s concerns and quoted extensively from the letters sent to Hunt.

In response, Norman Lamb MP, minister for care and support, said during the debate: “Concerns were raised that joint committees might not meet in public. Joint working does not need to mean that it will take place behind closed doors and exactly the same responsibilities will apply to CCGs when they work jointly as when they work on their own or through committees in common. Indeed, I understand that committees in common have already on occasion met in public and I would always encourage accountable organisations to operate in public wherever possible. That is the approach that I seek to advocate.

“Finally, I repeat that we take on board the concerns of Healthwatch England. We intend to work with that body to ensure maximum accountability for the decisions taken as part of these joint committees.”

In its statement to NHE, Healthier Together said: “The legal changes voted through Parliament recently will not change the need for a private part of some meetings, as with all organisations. However, it must be reiterated that all substantive decisions must be taken in public, and this will not change.”

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