Tuesday, 21 May 2013

The Dawn of The Clinical Commissioning Groups And The NHS Reforms

Here's the full and complete text, with proper formatting, of the article I wrote for Your Thurrock and that is being serialised on that site at the moment.  It is a very long article but I hope you will stick with it to the end.

April 1st 2013 will be a date that goes down in history, for good or for bad, as the day the National Health Service changed as part of the Coalition’s top-down reorganisation of our most precious public service.  Gone will be the old Primary Care Trusts (PCTs) who commissioned the health services for their particular areas and in will come the new health commissioners – the Clinical Commissioning Groups (CCGs).  Whether this is a good thing is a matter for people in the present to argue and debate and for future historians to judge based on hindsight. 
However, to debate an issue, one must have the facts on the subject and the opinions of others to form one’s own opinion and to take one’s own position so I present to you the facts and the opinions surrounding the issue of CCGs.
The Facts Around Clinical Commissioning Groups
Primary Care Trusts have been viewed as bureaucratic behemoths with layers of unnecessary management.
The reforms of health and social care were outlined in the Health and Social Care Bill.  The Bill received Royal Assent and became the Health and Social Care Act 2012 on 27 March 2012. (http://en.wikipedia.org/wiki/Health_and_Social_Care_Act_2012)
As part of the reforms of the NHS brought into being by former Health Secretary Andrew Lansley, groups of General Practitioners (GPs) were formed.  These groups would become known variously as GP Consortia, GP Commissioning Groups and, ultimately, Clinical Commissioning Groups.
GP Pathfinder Groups were set up as the first CCGs.  These Pathfinder groups were to “operate in shadow form alongside the PCTs”.
By March 2011, 177 pathfinder CCGs had already been formed.
Effectively from April 1st, CCGs (and by implication, GPs) are being handed the purse strings to a large proportion - £65 billion - of the £95 billion NHS commissioning budget.
Since the introduction of the Health and Social Care Act, the CCGs have been shadowing the old PCTs with a view to taking over the commissioning of health services in their local areas.
Services that CCGs will be responsible for commissioning or buying will include: elective hospital care, rehabilitation care, urgent and emergency care, most community health services and mental health and learning disability services.
CCGs will work with patients and healthcare professionals and in partnership with local communities and local authorities.
CCG governing bodies must have at least one registered nurse and a doctor who is a secondary care specialist.
CCG boundaries will not normally cross local authority boundaries.
CCGs will be responsible for arranging emergency and urgent care services within their boundaries, and for commissioning services for any unregistered patients who live in their area.
All GP practices will have to belong to a CCG.
The newly formed NHS Commissioning Board (NHSCB) has the duty to make sure that all CCGs have “the capacity and capability to commission services successfully and to meet their financial responsibilities”.
The NHSCB was created in shadow form in June 2011 and became fully operational from April 2012.
The NHSCB will still be directly responsible for commissioning the following services: Pharmacy services, General Practice, Dentistry services and Specialist services (specialised services that are required by a limited number of people).
Local authorities will have to set up Health and Wellbeing Boards (HWBs) to “ensure that Clinical Commissioning Groups are meeting the needs of local people”.
HWBs will have members from CCGs, Directors of public health, Children’s services, Adult Social Services, Elected councillors and local HealthWatch branches (representing the views of patients, carers and local communities).
HWBs were in place in shadow form April 2012 and were be operational from April 2013.
(Quotes and reference material from http://www.phorcast.org.uk/page.php?page_id=259)
In a press release on the 14th March 2013, the NHS Commissioning Board made the following announcement: "In total, 43 of the 211 CCGs have been fully authorised, meaning they met all 119 criteria for authorisation.  A further 168 CCGs have been authorised with conditions, meaning they have some additional work to do before they fully meet the criteria. A total of 15 CCGs have also been issued with legal directions, meaning the NHS Commissioning Board, and in some cases neighbouring CCGs, will provide more formal development support, underpinned by legally-binding instructions. The effect of a direction is to either direct how the CCG must work with another CCG or the NHS Commissioning Board to exercise functions.” (http://www.commissioningboard.nhs.uk/blog/2013/03/14/wave4-auth/)
Thurrock CCG was one of the 15 groups who had been issued with legal directions.
At a meeting of Thurrock Council’s Health & Well-Being Overview and Scrutiny Committee on 4th December 2012, Mandy Ansell, Chief Operating Officer for Thurrock CCG, said that there would be no sanctions against GPs as healthcare providers but they would be "forced" into joining eventually, when questioned about GPs who were reluctant to join the group.
CCGs: From The Horse’s Mouth
Architect of the Health and Social Care Bill, Andrew Lansley, had a vision for the new NHS.  Below are some quotes of what that vision was:
“The clinical commissioning groups will be statutory bodies, and will therefore not be able to delegate the responsibility for such commissioning to any other organisation, including a private sector organisation.” (Hansard source (Citation: HC Deb, 14 June 2011, c657))
“…we are shifting the ownership of commissioning and the responsibility for the design and delivery of services from what is essentially a distant managerial organisation into one that is locked into the clinical decision making of doctors and nurses across the service.” (Hansard source (Citation: HC Deb, 14 June 2011, c653))
“…local general practices—together in a commissioning consortium—and their other health care professionals, meeting with the health and wellbeing board in the local authority, will be able to bring democratic accountability in order to ensure that they have in her town and surrounding area the necessary services, based on a strategic assessment of need in their area.” (Hansard source (Citation: HC Deb, 8 March 2011, c770))
“Consortia will be able to reinvest any savings they make from their commissioning budgets for patients into improving patient care and health outcomes for patients for whom they are responsible. We have also proposed that consortia should receive a quality premium based on the outcomes achieved for patients, similar at a consortium level to the quality and outcomes framework for individual practices. That will incentivise the consortium as a whole to deliver improving outcomes for patients.” (Hansard source (Citation: HC Deb, 8 March 2011, c759))
Following the ‘pause, reflect and improve’ exercise, Mr Lansley gave the following statement in response to the NHS Future Forum’s report: “In his report, Professor Field set out clearly that the NHS must change if it is to respond to challenges and realise the opportunities of more preventive, personalised, integrated and effective care. The forum said that the principles of NHS modernisation were supported: to put patients at the heart of care, to focus on quality and outcomes for patients, and to give clinicians a central role in commissioning health services.
“…One of the most vital areas of modernisation to get right is the commissioning of local services. For commissioning to be effective, the process of designing services must draw on a wide range of people, including clinicians, patients and patient groups, carers and charities. We will amend the Bill so that the governing body of every clinical commissioning group will have at least two lay members, one focusing on public and patient involvement and the other overseeing key elements of governance, such as audit, remuneration and managing conflicts of interest. Although we should not centrally prescribe the make-up of the governing body, it will have to include at least one registered nurse and one secondary care specialist doctor. To avoid any potential conflict of interest, neither should be employed by a local health provider. The governing bodies will meet in public and publish their minutes. The clinical commissioning groups will also have to publish details of all their contracts with health service providers.
“…Building on that multi-professional involvement, clinical commissioning groups will have a duty to promote integrated health and social care with regard to the needs of their users. To encourage greater integration between social care and public health, the boundaries of clinical commissioning groups should not normally cross those of local authorities. If they do, clinical commissioning groups will need to demonstrate to the NHS commissioning board a clear rationale for doing so in terms of benefit to patients.” (Hansard source (Citation: HC Deb, 14 June 2011, c644))
He continued: “We will further clarify the duties on the NHS commissioning board and clinical commissioning groups to involve patients, carers and the public. Commissioning groups will have to consult the public on their annual commissioning plans and involve them in any changes that would affect patient services.
“…However, individual clinical commissioning groups will not be authorised to take over any part of the commissioning budget until they are ready to do so. Individual GPs need not take managerial responsibility in a commissioning group if they do not want to, and April 2013 will not be a “drop dead” date for the new commissioners. Where a clinical commissioning group is not able to take on some or all aspects of commissioning, the local arms of the NHS commissioning board will commission on its behalf. Those groups that are keen to press on will not in any way be prevented from becoming fully authorised as soon as they are ready.” (Hansard source (Citation: HC Deb, 14 June 2011, c645))
“It is precisely that process of engaging clinicians, who will come together to design services around the needs of patients in a way that delivers not just improving productivity, but improving quality of services for patients, that is at the heart of the shift from primary care trusts and strategic health authorities. Let’s face it: the Labour party spent a decade presiding over declining productivity, while the costs of bureaucracy and management in the NHS doubled. We will empower people in the NHS to deliver improving services and reduce bureaucracy.” [emphasis added] (Hansard source (Citation: HC Deb, 14 June 2011, c649))
“…sustaining the structure that we inherited from the Labour party, with all the strategic health authorities and all the primary care trusts—this vast bureaucracy— could never have happened. We had to take out administration costs in the service…” (Hansard source (Citation: HC Deb, 14 June 2011, c650))
“It is essential to move to a world where we reduce administration costs, relieve bureaucracy in the service and free those providing services by offering them the resources to deliver improving care without the burden of bureaucracy, cost and waste inflicted by a Labour Government in the past.” [emphasis added] (Hansard source (Citation: HC Deb, 14 June 2011, c652))
“It is because I believe in the NHS and the people who work in the NHS that I think it right to listen to and engage with those people, and to give them much greater control of the service that they provide for patients.” [emphasis added] (Hansard source (Citation: HC Deb, 14 June 2011, c655))
“Many GPs across the country understand that clinically led commissioning is the right thing to do, but they do not personally want to be involved in that process. There are, however, leaders who do, and leaders across the country have already come forward through pathfinder consortia and will be a basis on which we can create much greater clinical leadership across the service.” [emphasis added] (Hansard source (Citation: HC Deb, 14 June 2011, c658))
“We are going to transfer resources from bureaucracy, management and administration into front-line care. Through clinical commissioning groups we are going to empower staff in the NHS, and abolishing two tiers of management…” (Hansard source (Citation: HC Deb, 14 June 2011, c659))
“General practice—not just general practitioners but general practice—has a central role for patients because there is a long-term relationship with patients and an understanding of the whole population and the health of a whole area. However, GPs recognise that in order to get the right services for patients, they have to design services alongside the range of professionals whose job it is to deliver them.” (Hansard source (Citation: HC Deb, 14 June 2011, c660))
In response to Ronnie Campbell’s assertion that the Health and Social Care Bill was “a slow-privatisation-of-the-NHS Bill”: “This Bill and our proposals were never to support privatisation; they are not to support privatisation and they will not be to support privatisation.” (Hansard source (Citation: HC Deb, 14 June 2011, c660))
The Rise Of The CCGs In Quotes and Media Coverage
An Ipsos MORI/BMA poll of 1,645 BMA members, conducted in January 2011, found that the vast majority of respondents did not believe that the potential benefits of the NHS reforms outweighed the risks.
Other findings of the survey included: 89% agreed that increased competition in the NHS would lead to a fragmentation of services, 65% agreed that increased competition in the NHS would reduce the quality of patient care, 66% agreed that the move for all NHS providers to become, or be part of, foundation trusts would damage NHS values and 66% agreed that the proposed system of clinician-led commissioning would increase health inequalities whilst 49% believed that it would reduce the quality of patient care.
The survey suggested that doctors believe the changes that are most likely to be achieved are those which are least welcome and that the changes that would be most beneficial are least likely to be achieved.
61% reported that it was likely that the reforms will lead to them spending less time with patients, a change which only 1% would welcome. (http://www.ipsos-mori.com/researchpublications/researcharchive/2730/British-Medical-Association-BMA-Membership-Survey.aspx)  [3 March 2011]
A ComRes poll of 817 GPs for the Cancer Campaigning Group, conducted in May 2011, found that 82% of respondents believed that GP commissioners would need specialist support to commission cancer services effectively and that the quality of cancer care could be adversely affected if such support was not available.
Mia Rosenblatt, a member of the Cancer Campaigning Group’s Steering Group, said: “The overwhelming majority of GPs say they will need support to commission cancer services effectively. It is essential that the NHS Commissioning Board finds a way to retain the expertise in cancer networks so that consortia have access to the advice and guidance they require.
“The GPs surveyed also believed many key cancer treatments should be commissioned regionally or nationally rather than at a local level.  The Government must ensure that cancer patients receive the best quality care, regardless of who is commissioning the service.” (http://www.comres.co.uk/poll/11/cancer-campaigning-group-gps-survey-10-may-2011.htm)  [10 May 2011]
The NHS Alliance said that involving other NHS staff too heavily in CCGs could be damaging as hospital doctors may have an interest in promoting the profitability of their hospital - even though it may not be in the best interests of patients. (http://www.bbc.co.uk/news/health-13695849) [13 June 2011]
Nick Triggle, Health correspondent for BBC News, in reference to a proposed opt-out to CCGs for some areas, wrote: “Health Secretary Andrew Lansley has warned that if some parts of the country are allowed to opt out - even for a short-time - there is a risk that a two-tier system will be created.
“This happened in the 1990s, when half of GPs were given more responsibility under a system known as GP fundholding. It led to different standards of care in different areas.” (http://www.bbc.co.uk/news/health-13695849) [13 June 2011]
Dr Hamish Meldrum, chairman of the British Medical Association, in reference to concessions made during the ‘listening exercise’, was still not convinced the reforms were the right ones but said: "They may prove to be a distraction and we don't think the privatisation genie is back in the bottle, but we have to get on. There are big challenges ahead and that needs everyone to focus." (http://www.bbc.co.uk/news/health-13767584) [14 June 2011]
An Ipsos MORI/KPMG poll of 100 GPs, conducted in July 2011, found that “only a quarter think that their consortium will be ready to take on full commissioning responsibility by April 2013”.
Other findings included: 37% said that the government’s revised plans for clinically-led commissioning would be worse for patients than its original proposals, 28% said it would be better for patients than GP commissioning and 28% believed it would make no difference. (http://www.ipsos-mori.com/researchpublications/researcharchive/2831/A-quarter-of-GPs-surveyed-think-their-consortium-will-be-ready-to-take-on-full-commissioning-responsibility-by-April-2013.aspx) [11 August 2011]
A survey, organised by NHS Alliance and the National Association of Primary Care, of 131 leaders out of 253 CCGs led to some interesting findings – with 36% of GPs and other leaders saying they felt under pressure to become larger and 67% expressing fears that they might inherit debt from the old PCTs. (http://www.bbc.co.uk/news/health-14993000)  [21 September 2011]
Dr Michael Dixon, who heads the NHS Alliance, said: "Having a board with other clinical representatives and allowing for audit will be expensive.
"So the CCGs need to reach a critical mass in terms of size. But there's a risk of ending up recreating the old system of 150 primary care trusts.
"We're very concerned about the possibility of debts. My GP leaders don't want to be in the position of decommissioning services.
"It's been accepted that the CCGs shouldn't inherit deficits. But in practical terms, the squeeze on NHS finances is greater than people realise.
"Savings can be made in reducing referrals by GPs - but that won't achieve all the efficiencies that are needed.
"So there's concern not just about deficits but also the ongoing savings that are needed - and whether the CCGs will have sufficient budgets. It could be a double whammy." (http://www.bbc.co.uk/news/health-14993000)  [21 September 2011]
The Clinical Commissioning Coalition, set up to represent the CCGs, said doctors from 40 CCGs felt they were being blocked and coerced by local health chiefs.  Some of the complaints reported by the CCGs were that groups were being told to merge with others because they are considered to be too small whilst others were being threatened by having their CCG application blocked to stop them taking on their new responsibilities, meaning the then current managers would retain control of the budget.
The Government, however, refused to set an upper or lower limit on the size of any CCG, wanting instead a natural evolution for the groups. (http://www.bbc.co.uk/news/health-16009998)  [5 December 2011]
Mike Dixon, one of the founding members of the Clinical Commissioning Coalition, said too many managers from PCT clusters were "stuck in the past".
"It is bullying and coercion and if we are not careful GP leaders will get disgruntled and walk away, and GP practices will not want to be part of it.
"All of what we wanted to achieve will be lost." (http://www.bbc.co.uk/news/health-16009998)  [5 December 2011]
David Stout, of the NHS Confederation, said: "There will always be tensions and frustrations during periods of transition. In some cases PCT clusters will be reluctant to change, but in others they may be doing it for good reason.
"But the problem now is that it is starting to undermine confidence. We need to have adult conversations about this and make sure we get it right." (http://www.bbc.co.uk/news/health-16009998)  [5 December 2011]
The Royal College of Nursing (RCN) and the Royal College of Midwives (RCM) made quite clear their "outright opposition" to the NHS Bill, which mirrored Unison’s (that represents administration and support staff) position. (http://www.bbc.co.uk/news/health-16618207)  [19 January 2012]
The British Medical Association opposed the plans in 2011. (http://www.bbc.co.uk/news/health-16618207)  [19 January 2012]
Peter Carter, general secretary of the RCN, stated: “The sheer scale of member concerns, which have been building over recent weeks, has led us to conclude that the consequences of the bill may be entirely different from the principles which were originally set out.” (http://www.bbc.co.uk/news/health-16618207)  [19 January 2012]
Cathy Warwick, of the RCM, said: "The government has failed to present sufficient evidence that its proposals are necessary. They have failed to present evidence that the upheaval will result in an improvement in services to the people of England.
"And they have failed to answer the concerns of the people who fear for the future of the NHS under these plans." (http://www.bbc.co.uk/news/health-16618207)  [19 January 2012]
The Health Service Journal, Nursing Times and British Medical Journal published a joint editorial piece saying that the reforms were unlikely to be stopped but predicted the changes would be so destructive another reorganisation would be needed within five years. The NHS reforms were labelled as "unnecessary, poorly conceived and badly communicated" and had "destabilised and damaged" the NHS, adding that due to a combination of hasty compromises, a lack of confidence among staff and badly drawn-up proposals, the new system would be "unstable". (http://www.bbc.co.uk/news/health-16788328)  [31 January 2012]
Editor-in-chief of the BMJ, Dr Fiona Godlee, said the three publications decided to issue the joint editorial to illustrate the depth of feeling within the health service.
"We don't represent anyone, but we do talk to the doctors, nurses and managers who will have to implement these changes and wanted to get across the sense of anger at what has happened." (http://www.bbc.co.uk/news/health-16788328)  [31 January 2012]
A Department of Health spokesman said: "Our reforms are based on what NHS staff themselves have consistently said - they want more freedom from day-to-day bureaucracy and political interference so they can get on with the job of caring for patients. That is exactly what this bill achieves.
"…The Future Forum demonstrated widespread agreement with the principles of change and GPs themselves have written to newspapers to express their support.” (http://www.bbc.co.uk/news/health-16788328)  [31 January 2012]
BMJ Open, a member of the British Medical Journal group, published a report, based on a survey of 564 GPs, that found that many were suffering from high levels of emotional exhaustion and a reduced sense of personal accomplishment, particularly those who repeatedly saw the same patients. (http://www.bbc.co.uk/news/health-16788328)  [31 January 2012]
The BMA was reported to have said that the Government policy is incoherent and that major changes had been taking place before the bill had even been passed [emphasis added].
In a letter to The Telegraph, 56 GPs, part of a coalition formed by the NHS Alliance and the National Association of Primary Care, wrote: "Without strong clinical leadership and the co-ordinated efforts of local clinicians, the NHS itself may be in peril; local services can only be improved if we all pull together."
It adds: "Blanket opposition to the NHS reforms by the British Medical Association and the Royal College of Nursing is not representative of the views of GPs who, like us, already lead CCGs, and the large numbers of GPs and nurses who support us."
The Medical Practitioners' Union (MPU) - a sub-section of Unite, however, asked questions on how representative the coalition of medical groups was. Dr Ron Singer, president of the MPU told the BBC that the number of GPs who had signed the coalition’s letter was "infinitesimal".
Dr Singer said that in just six weeks before the Health and Social Care Bill went to the House of Lords, the MPU had collected more than 500 GP signatures of those involved in CCGs who wanted the Bill to be withdrawn, or time given for amendments to be made.
The MPU's petition stated: "Poor law, on top of the £20bn efficiency savings target for the NHS over the next five years, will put more lives at risk now and in the future."
Dr Singer said GPs had joined CCG's "because they want to protect their patients - not because they agree with the Bill".
The debate continued to rage as a poll taken by the Royal College of GPs suggested that 90% of family doctors supported calls for the Bill to be withdrawn. (http://www.bbc.co.uk/news/health-16771304)  [2 February 2012]
CCGinsider wrote: “Commissioning decisions are critical.  They determine where precious, limited NHS funding is allocated.  They set the strategy.  They determine which redesign projects are worth investing in and which are not.  GPs are uniquely placed to make these decisions.  They understand the needs of the patients they see on a daily basis.  They are often leaders within their local communities.  They experience through their patients the impact of changes to the health system.  There is no one better placed to lead commissioning.  There is no one more able to put patient needs at the heart of commissioning decisions.  It is not just important that GPs lead commissioning, it is essential.” (http://ccginformation.com/?p=63)  [26 February 2012
A spokesman for the Department of Health said: “Our plans will harness the expertise of local doctors and nurses, who know better than anyone what their patients need.
"The proposals promote health in partnership between the NHS and local communities and put local authorities in the driving seat alongside clinicians for improving the health of their communities.
"Improving integration between all health and care services is a crucial part of modernising the NHS." (http://www.bbc.co.uk/news/uk-politics-17169519)  [26 February 2012]
Discussing rumoured opposition in the Cabinet to the NHS reforms, Labour leader Ed Miliband said: "Nurses, doctors and patients have been telling David Cameron for months that he's on the wrong track on the NHS and now even members of his cabinet are as well.
"He should drop this bill, which is wasting billions of pounds on a bureaucratic re-organisation of the NHS and threatens a creeping privatisation of the National Health Service." (http://www.bbc.co.uk/news/uk-politics-16976199)  [27 February 2012]
Lord Crisp, former NHS chief executive and the permanent secretary at the Department of Health from 2000 to 2006, in a statement on BBC Radio 4's The World This Weekend in February 2012, stated: “"I think the great mistake that the current government has made - and I can say this as an independent and not a politician - is that this is a terrible confused and confusing bill.
 "It has tried to elevate the ideas of competition and the use of the private sector, which are just mechanics, just mechanisms, as if they were the purpose."
The Health and Social Care Bill was described as “the biggest shake-up since the founding of the NHS in 1948, putting GPs in control of much of its budget and encouraging greater competition with the private sector.” (http://www.bbc.co.uk/news/uk-politics-16976199)  [27 February 2012]
Dr Rish Prasad, a GP from Leicester, admitted that patients may not be happy about the changes and that his practice had already had to provide extra cover to allow GPs time for new commissioning schemes
He said: "As you pull GPs away from frontline clinical work, there will be disruption to services.
"That's not to say there will be less of a service - we're actually providing more clinical sessions. But you may not see the doctor you want to see, because they'll perhaps be doing other things.
"I can't be in two places at once - seeing patients and chairing a meeting." (http://www.bbc.co.uk/news/health-17343313)  [14 March 2012]
Professor Azhar Farooqi, Co-Chair of Leicester City CCG, said that his CCG still needed support from staff who can negotiate and monitor complicated contracts, which would be initially provided by then-current NHS staff.
He said: "In the short-term, we're planning to set up a commissioning support unit from staff previously employed by the Primary Care Trust cluster.
"But in the longer term, it's open for debate. We may continue that model, or go out to the market to get that support." (http://www.bbc.co.uk/news/health-17343313)  [14 March 2012]
The Royal College of Physicians (RCP) conducted a survey which showed that 69% of those members who responded (nearly 8,900 of the RCP's 25,000 members) rejected the NHS reform bill in its then-current form.  49% called for the bill to be scrapped whilst 46% called for the RCP to work with the Government on improving the proposals.  Only 6% approved of the changes as they stood.
RCP president Sir Richard Thompson said: "We believe that this is the single biggest survey among the medical royal colleges, with the highest turnout.
"The areas of most concern to RCP fellows and members are the areas on which we have been strongly lobbying government, MPs, peers and other stakeholders: training, education and research; use of the private sector; commissioning by clinical commissioning groups; and choice and competition"
"The quality of care that patients receive is clearly at the core of physicians' concerns and mirrors the key areas of the mission and objectives of the RCP." (http://www.bbc.co.uk/news/health-17398446)  [16 March 2012]
Health minister Lord Howe said: "While it is disappointing that some members of the Royal College of Physicians have voted to reject the Bill, it is worth noting that only a third of the college's 25,000 members voted in this process, and under half of those members have asked for it to be withdrawn. This is just 17 per cent of the RCP membership.
"We have already strengthened the Health Bill following the listening exercise and have responded directly to the points raised by the Royal College of Physicians, including making clear that competition would only be used to benefit patients, never as an end in itself." (http://www.bbc.co.uk/news/health-17398446)  [16 March 2012]
In his piece for The Independent on Sunday in 2012, Matt Chorley reported that two-thirds of CCGs had hired a bureaucrat, not a doctor, as their boss. (http://www.independent.co.uk/life-style/health-and-families/health-news/bureaucrats-return-to-lead-doctors-groups-7606225.html)  [1 April 2012]
The Health Service Journal (HSJ) conducted research that found that of 81 CCGs to have made appointments, 50 had chosen to hire an ex-PCT manager to lead them.
In fact, evidence of new complex management structures being put in place was making a mockery of Lansley’s plans to cut bureaucracy in the NHS with his reforms. (http://www.independent.co.uk/life-style/health-and-families/health-news/bureaucrats-return-to-lead-doctors-groups-7606225.html)  [1 April 2012]
Liz Kendall, a spokesperson for Health for Labour, said the reforms would be “creating a huge new bureaucracy" during the period 2012-2013 including 240 CCGs, local education and training boards, the NHS Commissioning Board, an NHS Trust Development Agency and clinical senates across the country. (http://www.independent.co.uk/life-style/health-and-families/health-news/bureaucrats-return-to-lead-doctors-groups-7606225.html)  [1 April 2012]
In response to the HSJ research findings, Andy Burnham, Labour's Shadow Health Secretary, said: "Andrew Lansley is spending billions of NHS cash on creating his new CCGs, but it turns out that many look suspiciously like PCTs, employing the same staff... It is yet more evidence that this vanity project is a damaging distraction and an unforgivable waste of money." (http://www.independent.co.uk/life-style/health-and-families/health-news/bureaucrats-return-to-lead-doctors-groups-7606225.html)  [1 April 2012]
Matt Chorley reported that “Redundancies in PCTs and health authorities will cost £56.5m, even though hundreds of staff are expected to join CCGs” and that doubt was being cast on whether the reforms would be able to achieve the savings the Government wanted them to make. (http://www.independent.co.uk/life-style/health-and-families/health-news/bureaucrats-return-to-lead-doctors-groups-7606225.html)  [1 April 2012]
A BBC poll of 814 GPs, carried out between 21 and 30 March 2012, showed that GPs were losing faith in the reforms. Only a small 12% agreed that having CCGs in charge of the budget would mean patients saw a "noticeable" improvement, which was a drop from 23% based on a poll carried out in September 2010.
A majority of those polled believed there would be more rationing of care because of financial pressures and 83% believed their own area would see an increase in rationing.
12% of GPs believed that CCG commissioning would improve care, 55% said they disagreed and 33% said that they were undecided on the issue.
On the subject of private healthcare providers, 87% of those polled agreed the changes set out in the health bill would lead to them having a bigger role.
49% of the GPs thought the NHS would not be able to go on meeting the 18-week target for routine treatments with just 22% thinking that it would be possible. A similar picture emerged for A&E departments, with 42% agreeing the NHS would need to close or downgrade some in the next five years. (http://www.bbc.co.uk/news/health-17604351)  [4 April 2012]
The King’s Fund chief executive Chris Ham stated: "GPs will be in the vanguard of this - their commitment is essential for implementing clinical commissioning, the government's big idea for ensuring that care meets the needs of patients.
"The public will judge the government's stewardship of the NHS on the basis of whether patient care improves, so ministers should be concerned that many GPs fear that care will get worse rather than better in the years ahead." (http://www.bbc.co.uk/news/health-17604351)  [4 April 2012]
British Medical Association's GPs committee chairman, Dr Laurence Buckman, said: "Increasingly, GPs are worrying that they will be blamed for making the hard decisions that may need to be made in order to meet the £20bn savings target set by the government. The government needs to be much more upfront with the public about the scale of savings that need to be made and why.
"If those who will have to deliver the latest health reforms are unconvinced and reluctant, the government should take notice of what they say." (http://www.bbc.co.uk/news/health-17604351)  [4 April 2012]
Andy Burnham, Labour's shadow health secretary, said the findings of the BBC poll were significant, adding: "Most GPs are clear that the NHS is going in the wrong direction and that the government's changes will make it worse not better. These results echo the concerns Labour has consistently raised and flatly contradict the reassurances given by the prime minister to get his Bill through." (http://www.bbc.co.uk/news/health-17604351)  [4 April 2012]
The NHS Confederation made the claim that the NHS reforms were in danger of creating a confused and fragmented service which might fail needy children such as youngsters in care and custody as well as those with mental health problems although those with complex health needs and disabilities could be affected too.
Five different parts of the NHS could be involved in organising services for vulnerable children including the NHS board, its regional offices, the GP-led clinical commissioning groups and Public Health England, a national body that will come under the remit of the Department of Health.
NHS Confederation’s deputy policy director, Jo Webber, stated: "We have ample evidence from the past of what goes wrong when organisations are not co-ordinated to work together properly.
"There is deep unease in the NHS that, in reorganising the system, we are resetting to a model that is potentially riskier and certainly more fragmented." (http://www.bbc.co.uk/news/health-17830799)  [25 April 2012]
Chris Naylor from The King’s Fund put forward the view that there may not be much difference between CCGs and the old PCTs, saying that “in terms of the population size they cover – a hugely significant issue for any commissioning body – CCGs and PCTs look increasingly similar” with the “median population covered by the 212 CCGs preparing for authorisation is 226,000, compared to 284,000 for the 151 PCTs they replace”.
He also stated that there were some caveats to bear in mind with regards to CCGs: “First, management resources will be lower for CCGs, and as a result of this more of their functions will be shared between CCGs or delegated to commissioning support services and other organisations. So the organisations themselves will be smaller than PCTs even if the population size they cover is comparable. In some cases the extent of sharing or delegation of commissioning functions may raise the question of whether the size of each individual CCG is the most important issue.
“Second, while the degree of variability may be similar for CCGs and PCTs, the factors driving it could be very different. PCTs are administrative constructs, whereas the shape and size of CCGs has been influenced by a number of factors, including clinical flows, perceived ‘natural’ population groups, the pattern of professional relationships across a local area, and existing administrative boundaries. A CCG may be small (or large) for different reasons than those that determine PCT size.” (http://www.kingsfund.org.uk/blog/2012/07/ccgs-and-pcts-not-so-different-after-all)  [17 July 2012]
Amy Millband, in a piece about potential conflicts of interest posed by CCGs, wrote “…recent research by False Economy – a research group financed by the TUC – has highlighted some concerns relating to a large number of GPs who sit on Clinical Commissioning Groups.
“…The research by False Economy has identified that many of these GPs have a conflict of interest, as they have personal financial involvement in non-NHS providers.
“After analysis of information available about 50 Clinical Commissioning Groups, their members and their outside financial interests, False Economy found that in 22 Clinical Commissioning Groups over half of the GPs and in some cases all of them sitting on the boards have a stake in non-NHS providers of health care. In 10 Clinical Commissioning Groups it was shown that the majority of GP members were in partnership with Virgin Care to provide services ranging from physiotherapy to dermatology. For another 7 Clinical Commissioning Groups many of the GPs earned extra money through their work providing evening and weekend services for patients as part of “not for profit family doctor collectives”.” (http://www.luxurymedical.co.uk/2012/clinical-commissioning-groups-gps-and-their-conflicts-of-interest/) [19 August 2012]
Stephen Metcalfe MP said: “The establishment of a CCG in Thurrock is undoubtedly a step in the right direction.
“It will put the NHS back in the hands of local practitioners who best know how to meet local needs.” (http://www.thurrockgazette.co.uk/news/10118005.MP_meets_with_new_health_group/) [24 December 2012]
CCGinsider described CCGs as “groups of GP practices that decide how the NHS money is used in a way that means their local population is as healthy as possible and receives high quality care when they need it.  They use their understanding of their own patients, and their relationships with doctors, nurses and other healthcare professionals, to buy (‘commission’) the services that best meet their patients’ needs.  Because clinicians rather than managers are in charge, the NHS is safe in their hands.” (http://ccginformation.com/?p=297)  [2 February 2013]
Dame Barbara Hakin, NHS Commissioning Board’s National Director of Commissioning Development, said: “CCGs are a vital foundation of a new, clinically-led NHS that is focused on delivering improved health outcomes, quality, patient safety, innovation and public participation.
“CCGs will have wide-ranging responsibilities with regard to patient safety and will manage very large budgets, so it is vital that they are robust and capable of making important decisions. The NHS Commissioning Board has a duty to ensure CCGs have made arrangements to deliver their responsibilities, and we take that duty very seriously.” (http://www.commissioningboard.nhs.uk/blog/2013/03/14/wave4-auth/) [14 March 2013]
And here are some extracts from a piece posted here on Your Thurrock, taken from pulsetoday.co.uk; they are rather telling: “TWO PRACTICES have been forced to join their CCG by the NHS Commissioning Board against their wishes, in a move GP leaders say makes a mockery of Government claims the new bodies reflect implicit GP support for their reforms.
“The NHS Commissioning Board used its legal powers to force two practices in Essex to become members of NHS Basildon and Brentwood CCG and NHS Thurrock CCG – the two worst performing CCGs in the country – against their wishes.”
Of the 211 CCGs across the country who were supposed to take over commissioning duties from 1 April 2013 “only 43 CCGs have been fully authorised, and a further 153 have been authorised with minor conditions and 15 were given legal directions for an intensive level of support.”
The piece also stated that “GP leaders have warned that the forced allocation of practices onto CCGs demonstrates that GPs have no choice but to sign up to the Government’s reforms and reflect a lack of engagement with member practices in some areas.” (http://www.yourthurrock.com/2013/03/15/is-working-together-the-bitterest-pill-for-thurrock-doctors/) [15 March 2013]
Dr Chand Nagpaul, a GPC negotiator, said: “The idea that CCGs are membership organisations has always been a misnomer because all membership organisations give you a choice over whether to be a member or not.
“These are forced membership organisation and the Government has made it clear that those GPs that don’t agree to be in a CCG will be forced to be in the CCG. This is in keeping with the Government’s policy.” (http://www.yourthurrock.com/2013/03/15/is-working-together-the-bitterest-pill-for-thurrock-doctors/) [15 March 2013]
Dr Brian Balmer, chair of Essex LMC, stated that the problems in Essex reflected “historical splits” between practices within the CCG areas that had not been improved with the NHS reforms, adding: “I think commitment from GPs in general is not that strong and in some areas the GP leadership has struggled to bring them together in any sort of coherent way.
“In some areas there is some reasonable sign up. But I am not convinced GPs are truly signed up to the agenda. It is compulsory, they have got to be in CCGs. The Government will make a big thing of all practices being in CCGs, but they have no choice.” (http://www.yourthurrock.com/2013/03/15/is-working-together-the-bitterest-pill-for-thurrock-doctors/) [15 March 2013]
The NHS Commissioning Board stated that all GPs had a “legal requirement” to be members of CCGs. A spokesperson added: “The CCGs concerned have been working hard over the last few months to achieve sign-up and the relevant regional teams have been involved with this. As membership organisations, CCGs’ strategy and direction are set through consultation and engagement with their member practices.
“We would urge all GP practices to fully engage with their CCGs.” (http://www.yourthurrock.com/2013/03/15/is-working-together-the-bitterest-pill-for-thurrock-doctors/) [15 March 2013]
In his piece for the Independent on Sunday, Owen Jones summed up what a lot of people have been thinking: “Nothing is more gut-wrenching than watching a close friend dying in front of you. And I mean beyond close: a friend who brought you into the world, helped raise you, and was there whenever you were most desperately in need. So, spare a moment for our National Health Service. Time of death: midnight, 1st April 2013. Cause of death: murder.”
Regarding the under-reporting of the extent of the NHS reforms, he stated that: “The Health and Social Care Act is more than three times longer than the legislation that established the NHS in the first place. When I asked journalists adamantly opposed to the Tory plans why they had failed to adequately cover this travesty, they sheepishly responded it was too complicated: it went over their heads.”
CCGs are meant to be run by GPs but he states: “This is a sham, though one which turns local doctors into human shields for the privatisers. In reality, the vast majority of GPs will keep on doing what they do already – looking after patients – while commissioning will be managed by private companies.
It’s worse than that. Under the Government’s Section 75 regulations – even after they were revised after huge political pressure – all NHS services must be put out to competitive tender unless the commissioning groups are satisfied a “single provider” can deliver that service. But as the British Medical Journal has asked, how can they “be sure there is only one possible provider except by undertaking an expensive tender?”
Indeed, were they to refrain from doing so, they would risk a costly legal battle. As over a thousand doctors and nurses warned last month, the regulations will “force virtually every part of the English NHS to be opened up to the private sector”. A free-for-all in the English NHS beckons.” (http://www.independent.co.uk/voices/farewell-to-the-nhs-19482013-a-dear-and-trusted-friend-finally-murdered-by-tory-ideologues-8555503.html) [31 March 2013]
Dr Lucy Reynolds, a research fellow at the London School of Hygiene and Tropical Medicine, stated that “the public sector will shrink away, and the private sector will grow.” (http://www.independent.co.uk/voices/farewell-to-the-nhs-19482013-a-dear-and-trusted-friend-finally-murdered-by-tory-ideologues-8555503.html) [31 March 2013]

Professor Terence Stephenson of the Academy of Medical Royal Colleges stated that doctors’ warnings had been ignored, and “unnecessary competition [would] destabilise complex, interconnected local health economies, in particular hospitals, potentially having adverse effects on patient services”. (http://www.independent.co.uk/voices/farewell-to-the-nhs-19482013-a-dear-and-trusted-friend-finally-murdered-by-tory-ideologues-8555503.html) [31 March 2013]
Owen Jones added in his piece that: “The great sell-off of our NHS is already well under way. Virgin Care now run more than 100 NHS services across the country, from radiology departments to GP clinics. Last year, they were given a £100m contract to run services in Surrey, and a £130m contract to run key NHS services for young people in Devon. Not that you’d know, of course: services run by the profiteering vultures circling ahead operate under the NHS logo, hiding privatisation from public view.”
He concluded that: “It was Nye Bevan who said “The NHS will last as long as there are folk left with the faith to fight for it”. It is with huge regret that I must say that – however much faith we have – we did not fight to save it. The NHS has been killed, murdered, assassinated by a Tory government. The question now is – do we have enough faith to bring it back to life?” (http://www.independent.co.uk/voices/farewell-to-the-nhs-19482013-a-dear-and-trusted-friend-finally-murdered-by-tory-ideologues-8555503.html) [31 March 2013]
Now It Is My Turn…
When I was first asked to write this piece a few weeks ago I thought that it would easy to cobble something together on CCGs.  How wrong I was.  Firstly, it’s difficult to tease out the CCG-specific stuff from the debate surrounding the whole NHS reforms. Secondly, as the CCGs are the bedrock upon which the NHS will be re-built, discussion of the wider reforms has to be included as they have a part to play in the back-door privatisation of the NHS.  Thirdly, it has been hard to find quotes that did not combine aspects of both issues.  Finally, as I have no computer at home now following the death of my laptop and PC, I have only two hours a day on the computers in Grays library in which to complete the search for research material and write up the piece – not an easy task I assure you.
However, here are my views on CCGs and I will not mince my words.
Let me begin with something that may surprise my right-wing critics – I actually believe that the idea of clinician-led commissioning is a good idea.  I think that GPs probably are best placed to inform local commissioning, however, that is where the agreement ends.  The way in which clinically-led commissioning could have been put in place did not need to be done in the way in which the Government has done so.
Let us be very clear on this point – the work on which the disbanding of the PCTs and creation of the CCGs was started on an illegal footing.  The Health and Social Care Bill on which the work was performed was not law at the time the foundations of the changes to the NHS were being laid.  Pathfinder CCGs were in place a year or so before the Bill gained Royal Assent and entered into law.  To enact pieces of a Bill before it becomes an Act of Parliament is not just wrong, it is unconstitutional and illegal.  All that is allowed is for a Government to inform the affected agencies that these are plans that they wish to enact should it become an Act of Parliament, allowing those agencies to prepare for the changes should they happen.  The illegality of the work done to enact a proposed Bill as law makes the entire creation of the CCGs and disbandment of the PCTs suspect.  Even the setting up of the NHS Commissioning Board in a shadow form was done before the Bill became an Act so is equally suspect.
To continue, I will look at each statement or opinion I have cited above and give my response.
Lansley stated that CCGs would not be able to delegate their commissioning powers to private companies; he does not state that private companies could not have an influence on the commissioning though.  Comments made by Amy Millband and Owen Jones do highlight the influence that private healthcare companies may end up having on the CCGs and any decisions they may make regarding who to award healthcare service contracts to.
Lansley stated that the Government was handing responsibility for commissioning from “a distant managerial organisation” to clinicians, which sounds great; however, on 1 April 2012, it was reported that two-thirds of CCGs had employed “a bureaucrat, not a doctor, as their boss”.  On this evidence alone, it appears that the decisions may not be being totally handed over to clinicians as Lansley suggested.  It also occurs to me that the Government is trying to wash their own hands of the responsibility of healthcare, which is supposed to be their responsibility.  Is this an attempt for the Government to be able to say that it is “not their fault” should the reforms fall on their backside?  Is this not just an attempt to find yet another scapegoat for any future failures?
Don’t get me wrong here – I hope that the doomsayers are wrong and that these reforms do have the desired effect of putting clinicians at the heart of commissioning but I, and many others, have our doubts.  This could all be a devious attempt to blame CCGs and give the Government the chance to say that the reforms failed, not because their policies were ill-considered but because the CCGs screwed them up, keeping the Government’s hands clean.
Lansley stated that GP commissioning would “based on a strategic assessment of need in their area” which also sounds great on paper and, I have to say, might work.  However, it is a widely known fact that, even under the PCTs, there was a ‘postcode lottery’ regarding health and there is no proof either way whether CCG commissioning will solve that problem.  Take mental health, for instance; many GPs have very limited understanding of mental health issues and many have an interest in the more usual physical health conditions (heart disease, cancer, etc.), this may end up creating a situation where mental health (already seriously under-funded for the amount of the population that suffers with mental health issues) will end up getting even less money in some areas simply because their CCG does not have anyone who understands or is willing to list spending in that area of healthcare as a priority.  At least PCTs had an overview of healthcare in general and experts in all areas of healthcare and its commissioning.
Lansley stated that any savings made by CCGs could then be reinvested in their commissioning budgets and I cannot fault the intention; however, a number of things occur to me – 1) what happens if the CCGs over-spend on their budget? 2) Can we really trust GPs to reinvest that money in the commissioning budget?  Who’s going to oversee that that happens? And 3) how can we be entirely sure that GPs will not make sure that they benefit from interests in private healthcare companies by commissioning less able companies they have interests in over more able ones to ensure that their budget is entirely used up?  There’s nothing to stop GPs with private interests from doing deals with other GPs to ensure that deals that profit them happen in a quid pro quo arrangement.
I do not think that anyone could argue that we need “more preventive, personalised, integrated and effective care”, that we should have “quality and outcomes for patients” and that clinicians should have “a central role in commissioning health services”.  The question is will these reforms deliver on those outcomes or could they have been achieved by tweeking the PCTs instead of getting rid of them?
The idea of getting the commissioning of local services right is an admirable and necessary one and it is nice that lay members will be on the CCG boards.  The idea of having “at least one registered nurse and one secondary care specialist doctor” who will not be employed by a local health provider on board is also a reasonable one; however, with the interconnectedness of companies these days, who is to say that hidden conflicts of interest may not happen?  What safeguards are in place to ensure that hidden conflicts of interest are found so that a board member may be replaced with all due speed?
Holding CCG meetings in public is vital for transparency and public accountability as is the publishing of contracts the groups may enter into; however, is that not the case for any publically accountable body?  PCT meetings were open to the public as well so it is not as though Lansley’s plans have added something that was not already there in the first place.
There is no doubt that we need to “promote integrated health and social care with regard to the needs of their users” but could that not have been done by careful tweeking of the old PCTs?
There is a rather big problem with the idea that “the boundaries of clinical commissioning groups should not normally cross those of local authorities”, especially in Thurrock, being as it is a unitary authority and a lot of the services the residents of Thurrock rely on are based outside of the authority.  This being the case and with the neighbouring authorities being larger, is it possible that Thurrock’s needs may end up being not ignored but side-lined in favour of the greater area?
The need to involve patients, carers and the public goes without saying, however, that was already happening with the PCTs so is not exactly adding anything new to the NHS.  Of course, the PCTs may not have had great success with their public consultations in the past but the question is - can CCGs do any better?  That is the million dollar question and we must await the answer with baited breath.
The idea that “individual clinical commissioning groups will not be authorised to take over any part of the commissioning budget until they are ready to do so” only makes sense; however, as the date for CCGs to take over was 1st April 2013 and at least 15 CCGs (including Thurrock CCG) had to be given legal directions as they were deemed ‘not ready’, local branches of the NHSCB would be commissioning on their behalf so would it not have been wiser to postpone the breakdown of the PCTs until all the new CCGs were in place and ready to assume their duties?
Lansley stated that bringing clinicians into the commissioning process would assist in “improving productivity”, “improving quality of services for patients” and would “reduce bureaucracy”.  On the subject of bureaucracy, Lansley also stated that “We had to take out administration costs in the service…” and that the reforms would “relieve bureaucracy in the service”.  Bold statements - but where is the proof?  GPs themselves were sceptical on the reforms delivering improved quality of services as shown in a BBC poll of 814 GPs in March 2012 in which “12% of GPs believed that CCG commissioning would improve care, 55% said they disagreed and 33% said that they were undecided on the issue” and “83% believed their own area would see an increase in rationing” of health services.
Regarding the reducing of bureaucracy, research published in April 2012 found “evidence of new complex management structures being put in place” which includes “240 CCGs, local education and training boards, the NHS Commissioning Board, an NHS Trust Development Agency and clinical senates across the country.”  Now, correct me if I am wrong but that seems like a lot of bureaucracy to me; indeed both Andy Burnham and Chris Naylor from The King’s Fund saw a great deal of similarity between the new CCGs and the old PCTs.
And as for reducing costs, the reforms are costing “billions of NHS cash” with £56.5 million being spent on redundancy payments for PCTs and health authority staff “even though hundreds of staff are expected to join CCGs”.  There was also doubt that the reforms would achieve the savings they are supposed to make anyway.
Lansley stated that it was “right to listen to and engage with” the people who worked in the NHS so why did he ignore the protestations of the very people he insisted he should listen to when there was sufficient evidence of their opposition?
Lansley’s assertion that many GPs understood that clinically led commissioning was the right thing to do cuts no ice with me as I understand that putting clinicians at the heart of commissioning is a good idea.  That does not mean, however, that they supported the reforms or wanted to be forced into joining CCGs when they could have easily joined the boards of tweeked PCTs with reduced cost implications and less upheaval for the NHS than the current reforms.
Lansley stated that his reforms would succeed in “abolishing two tiers of management”; however, from the evidence, all he has actually achieved is moving those management tiers down from the PCT level to the closer-to-ground-level CCG level with at least some of the same staff being a part of the new structure.
I agree, in some respects, with Lansley’s assertion that GPs have “a long-term relationship with patients” although you have to admit that that does not necessarily mean that the relationship is a good one or, indeed, means that the GPs in question understand the entire population and the needs of the area.  For example, my relationship with my GP consists of going to the surgery, being prescribed my medications that are not on the repeat prescription form and leaving.  This does not mean that my doctor understands my mental health condition; merely that she can record my details on a more regular basis than my consultant psychiatrist.
The fact that Lansley added that GPs would have to “design services alongside the range of professionals whose job it is to deliver them” does not really bolster the case for his reforms either because the old PCTs had that range of professionals at its fingertips already and, with some tweeking, GPs could have been included on a greater level with the PCTs.
Lansley stated that his reforms “were never to support privatisation; they are not to support privatisation and they will not be to support privatisation”; however, a large proportion of NHS services have been contracted out to private healthcare companies already.  Only the most profitable services though.  The rest remain under the control of the NHS itself.
Privatisation is also difficult to deny when CCGs are able to commission the services from any provider.
A poll of members of the BMA were worried that any potential benefits would be outweighed by the risks in the reforms and that they would fragment services, negatively affect patient care and damage NHS values.  And there have been repeated calls by the medical profession to abandon or reduce the size of the reforms being made.  This just goes to prove that the Government was not listening to the people they supposedly valued the input of.  Hardly the basis for a successful reformation process.
The reforms also did not seem to take into account the necessity for specialist support when dealing with commissioning for specialist needs, something that was already in place under the PCTs.  Where was the support to come from?  The only people truly qualified to provide that support worked for the PCTs so it is only reasonable that CCGs hire those individuals to assist them.  So where does that leave the idea of cutting out bureaucracy?
Lansley stated that opting-out of the CCGs even for a short time might create a two-tier system in the NHS.  He did not seem to give any explanation for that hypothesis so where did he come up with that idea?  Or was it his intention to scare GPs and their colleagues into setting up a CCG?  So much for the idea of the scheme being voluntary.
The idea that privatisation was a real threat cropped up on more than one occasion and that threat is even more real now as an attempt to prevent the NHS from being opened up to competition failed in the House of Lords on 24 April 2013,  lost by 254 votes to 146.
The Mirror reported that: “Lord Owen, who sits as an independent crossbench peer but was a Labour foreign secretary in the 1970s, warned the regulations were part of the erosion of the traditional NHS.
“He told peers: "Don't think this is a minor step. If this goes through the National Health Service as we have seen it, as we have believed in it, as we have persuaded the electorate that we support it, will be massively changed.
"It will take five, 10, 15, maybe 20 years, but unless we pull back from this whole attitude there will be no National Health Service that any of us can recognise.
"I for one feel tonight one feeling only - overwhelming sadness." (http://www.mirror.co.uk/news/uk-news/section-75-last-ditch-bid-stop-1852287)  [24 April 2013]
Where does Lansley’s statement that his reforms were not paving the way for privatisation stand now?
There has been media coverage of the feelings of pressure both to join CCGs and for the CCGs to become bigger.  This seems at odds with the idea that the consortia were supposed to be membership organisations and at odds with the idea of scaling down the organisations in charge of commissioning.  True, Lansley is not in charge of the reforms anymore but Jeremy Hunt has not really added much to the plans or taken anything away from the Lansley masterplan.  Calling an organisation a ‘membership organisation’ when it is compulsory to join seems vaguely dictatorial, certainly not what you would expect in a democracy in which people are supposed to have a modicum of free choice in their decision making. And as the CCGs are looking more and more like the old PCTs, were the radical reforms Lansley proposed really necessary?  Surely, tweeking the old PCTs would have been cheaper?
There have been allegations that the reforms would create a fragmented service that would fail children such as those in care or custody and those with complex health needs and that there may be tensions within CCGs that may be problematical for the smooth running of the commissioning process.
There are worries that relying on CCGs for commissioning health services might lead to health inequalities and a ‘postcode lottery’ for certain conditions if there are no members championing those conditions.
And let us not forget - some CCGs have been deemed as not yet ready to assume their role as health service commissioners so is there not a danger of the two-tier system Lansley was so worried about regarding areas opting-out of CCGs happening anyway?
Are GPs any closer to wanting to have the power they have been given?  I certainly have not been able to find any polls to give an answer either way.  However, there was a certain amount of trepidation from shown in earlier polls with some GPs expressing worry that they will be held to account for the failure of the reforms.  Who can blame them from worrying when the Government seems to want to wash their hands of their duty?  Although I do have to say at this point that there are some safeguards and, ultimately, the Health Secretary has to carry the can.  How many CCGs and GPs will be thrown under the bus first though?  And how much damage will be done to the reputation of those groups and individuals who may not have wanted the commissioning power they were handed?
Ultimately, how much damage will be done to the organisation that is the envy of the world?  The organisation that makes this country great and was once called the closest thing this country has as a religion.
I hope for all our sakes that these reforms do not have the effect of killing the NHS, I truly do.  I hope that CCGs will be able to succeed in their aim of providing us with a better NHS than under the old PCTs.  I hope that I and other opponents of the reforms are wrong; I will gladly hold up my hands and admit I was wrong if that is the case.  However, looking at the evidence, I can say that I am not at all convinced that these reforms are not a huge mistake by a massively narcissistic Government who will not be affected by the reforms because they can afford to have private healthcare.
I hope that Owen Jones’ comment about the NHS is wrong: “Time of death: midnight, 1st April 2013. Cause of death: murder.”
Only time will tell.  It always does.

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