Back to the future: Covid-19 has increased the appetite for centralisation of decision-making
Updated: Jul 29
NHS England is set to achieve its commitment to roll out Integrated Care Systems (ICSs) across England by April 2022, which will replace clinical commissioning groups (CCGs) by centralising their functions.
Post by Higia Vassoler, Senior Consultant
NHS England is set to achieve its commitment to roll out Integrated Care Systems (ICSs) across England by April 2022, which will replace clinical commissioning groups (CCGs) by centralising their functions. A total of 42 ICSs spread across 13 geographical areas, will bring together hospital, community and mental health trusts, GPs and other primary care services with local authorities and other care providers. These reforms will undoubtedly lead to greater integration of healthcare services, but what will it mean for patients, pharmaceutical commissioning, and market access?
Clinical commissioning groups (CCGs) were created following the Health and Social Care Act in 2012 and replaced Primary Care Trusts on 1 April 2013. CCGs have successfully acted as clinically-led NHS bodies responsible for setting priorities, planning and commissioning healthcare services for their local area. In the year 2019/2020 the budget for the commissioning of local services through CCGs reached £79.9 billion, taking up over two-thirds of the total NHS budget 1,2.
Over the years, the number of CCGs has gradually decreased following a series of mergers under a voluntary process that saw over 191 CCGs as of 2019 merge into about 130 CCGs as of 2021. Notably, the 2010 white paper "Equity and Excellence: Liberating the NHS" originally laid out the intended direction of the government, for the creation of a clinically-driven commissioning system that was more sensitive to the local needs of patients.
Critics of the NHS Long Term Plan, which includes the roll-out of ICSs among other reforms, claim that abolishing CCGs altogether could roll back 30 years of reorganisations that have managed to use primary care knowledge to improve allocation of resources in the NHS. By effectively replacing CCGs with a more centralised network of ICSs, the NHS will see deeper integration across health and local government. The drive for greater integration might go even further, with ICSs covering a population of less than a million likely to merge further down the line, as the NHSE indicated that ICSs will need to be of “sufficient size” to work effectively 3.
Moreover, specialised services would be increasingly organised at ICS level with the NHSE introducing population-based specialised commissioning budgets at a regional level. A new “single budget pot” would bring together current CCG commissioning budgets, primary care budgets, the majority of specialised commissioning spend, the budgets for certain other directly commissioned services, central support or sustainability funding and the nationally held transformation funding under the domain of ICSs 3.
These reforms will result in fewer commissioners who will become responsible for larger geographical areas and consequently larger contacts. Controversially, section 75 of the Health and Social Care Act 2012 – which mandated for all NHS contracts to be put out to competitive tender – will be scrapped 4. To this effect, pharmaceutical manufacturers and service providers may benefit from more flexible procurement with reduced legal bureaucracy on one hand, but perhaps at the cost of a less transparent payer decision-making framework on the other hand. NHS England and NHS Improvement (NHSE/I) are currently consulting on how a new procurement regime would operate and exploring future legislation that streamlines the current procurement rules, reduces the need for unnecessary competitive tendering and reduces uncertainty for providers 5.
For patients, it is widely expected that the more centralised approach to allocation of resources provided by ICSs may have positive implications in terms of reducing local variations in access to services, an issue widely known as the “NHS postcode lottery” 6,7. Overall, it remains to be seen what the impact on patients will be and whether the benefits of a more joined up and less bureaucratic structure for healthcare delivery and commissioning, will make up for the reduced scope for local-level service prioritisation. For manufacturers, more centralised budgets offer greater certainty around planning and access, although these benefits may come at the cost of increased pressure for price-volume discounts and commercial agreements.
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1. Iacobucci G. NHS’s plan to abolish CCGs must not dilute primary care’s influence, say leaders. [last accessed on 29th March 2021, www.bmj.com/content/371/bmj.m4730 ]
2. NHS England and NHS Improvement funding and resource 2019/20: supporting ‘The NHS Long Term Plan’ - NHS England and NHS Improvement; First published: 29 March 2019 [last accessed on 29th March 2021, www.england.nhs.uk/wp-content/uploads/2019/03/nhse-mhsi-funding-and-resource-2019-20-supporting-nhs-ltp.pdf ]
3. NHS England recommends law to abolish CCGs by 2022 | Local Government Chronicle (LGC) [last accessed on 29th March 2021, www.lgcplus.com/services/health-and-care/nhs-england-recommends-law-to-abolish-ccgs-by-2022-27-11-2020/ ]
4. CCGs to become part of ICSs under wide-ranging NHS reforms [last accessed on 29th March 2021, www.pulsetoday.co.uk/news/nhs-structures/ccgs-to-become-part-of-icss-under-wide-ranging-nhs-reforms/ ]
5. NHS reorganisation update: ICS on statutory footing by April 2022 [last accessed on 29th March 2021, www.health-and-care-update.co.uk/2020/11/nhs-reorganisation-update-ics-on-statutory-footing-by-april-2022.html ]
6. NHS postcode lottery persists for most vulnerable patients – Which? News, By Oliver McKean 24 Jul 2019 [last accessed on 29th March 2021, www.which.co.uk/news/2019/07/nhs-postcode-lottery-persists-for-most-vulnerable-patients/ ]
7. NHS failing stroke patients with 'postcode lottery rehabilitation' | Stroke | The Guardian, www.theguardian.com