NHS commissioning landscape about to become treacherous

Commission accomplished? A landscape that once stood on the precipice of functionality has since become a treacherous maze.

I have a useful ‘pivot table’ listing the 209 CCGs and their 140 Chief Officers, some of whom head up five or more CCGs. These numbers reduce weekly. There were originally 303 PCTs in 2001, then 152, before being grouped as 49 PCT ‘clusters’, via a process of appointing shared managers across what were, technically, separate entities.

Fifteen years ago, I worked in the first PCT cluster – a de facto merger of three PCTs. Indeed, we used to have board meetings with three logos on the bottom of the page. This was a clever idea; effectively, a merger
of statutory bodies which negated legislation, reduced management costs (slightly) and made the most of managerial ability.

PCT clusters were compulsory from 2011, with financial and waiting time target performances evened out on a geographical basis, meaning that groups of under-spent and over-spent PCTs could be linked to achieve one balanced budget.

I was one of the first managers trained for the world of ‘purchaser-provider splits’ in 1991, and moved to commissioning because I truly believed in a future of planning, health economics, evidence-based protocols and care pathways measured against specification.

I subsequently worked on the ‘PCT Fitness for Purpose’ programme, which led on to the World Class Commissioning concept initiated exactly 10 years ago. We talked about higher qualifications in NHS commissioning, and the possibility of clinicians joining the commissioning melting pot. That seems utterly laughable now.

For 25 years too many PCTs and CCGs have simply been temporary piggy banks, used to pass money directly to providers. Meanwhile, as others have engaged in blame exchanges, dressed up as contracting, only a few have delivered things that actually benefit patients. Through all of that, we have endured tenders, endless meetings, finance transaction costs and the disheartening culture of intelligent people being distracted from improving real healthcare.

Commissioning failed because the constituency of support wasn’t there. The public never got it and therefore commissioners had no mandate, whereas the providers never lost that endorsement because ‘it came with the stethoscope’. Repeated re-organisation has destroyed even the faintest chance of commissioning being scientific, professional and sophisticated. Putting public health into local councils was the final straw, with GPs unable to influence accountant-led CCGs.

I think CCGs will consolidate to SHA size with primary care home hubs designing local pathways using devolved budgets. The internal market will wither away and be replaced by integrated health economy planning – so a bit like Scotland and Wales, but with provider performance scrutiny.

No doubt you lot are ready for this and what it means for your company, products and role. If so, believe me, you’re ahead of the NHS!

Central characters

CCGs – Clinical Commissioning Groups replaced PCTs during a restructure five years ago.

PCTs – Primary Care Trusts were responsible for NHS commissioning between 2001-2013.

SHA – Strategic Health Authorities led the development of local health services. Closed in 2013.

Pivot table – Jewel in the Microsoft Excel crown, this enables users to extract sense from a seemingly mind-boggling data set.



David Thorne is Chair, Washington Community Healthcare and Non-Executive Director, City and Vale GP Alliance. Go to blueriverconsulting.co.uk