Research News

Clinical commissioning groups serve too many masters, finds study

BMJ 2013; 347 doi: (Published 13 December 2013) Cite this as: BMJ 2013;347:f7501
  1. Zosia Kmietowicz
  1. 1BMJ

Clinical commissioning groups (CCGs) are accountable to too many masters with potentially competing agendas, say authors of a study in the online journal BMJ Open.1

CCGs, which replaced primary care trusts in April this year and which are responsible for 65% of the NHS budget in England, were set up in part to boost the accountability of those responsible for commissioning care for patients. They also have greater autonomy than their predecessor organisations, but this independence depends in large part on their relations with the bodies that oversee them.

To understand the accountability of CCGs better, the authors looked in detail at how eight of these new organisations were developing.

Between September 2011 and June 2012 they interviewed 91 people, including GPs, managers, and governing body members. They also sat in on many meetings, totalling 439 hours, and analysed a range of documents.

The study found that CCGs were accountable to NHS England, the regulator Monitor, local health and wellbeing boards, local Healthwatch groups (which represent service users), the public, local medical committees, and the local authority’s overview and scrutiny committee. They were also internally accountable to the CCG governing body, member practices, and locality groups.

The authors concluded that CCGs were more accountable than were primary care trusts. They described the CCGs as being “at the centre of a complex web of accountability relationships, both internal and external.” But they added, “Whether this translates into being more responsive, or more easily held to account, remains to be seen.”

Previous research indicated that complex accountability arrangements tended to generate confusion, the authors said, “and where organisations are accountable to multiple audiences, the interests of these audiences may differ, generating unintended consequences.”

The accountability relationship with NHS England was the only one that was clearly defined and where sanctions applied, the authors pointed out. “The accountability to other external bodies, such as Health and Wellbeing Boards, is, by contrast, much weaker,” they say.

Accountability to Monitor may be enforced by competition law, but it was unclear how this would work in practice, the authors said. By contrast, accountability to the public was political and based on “the relatively weak notion of ‘transparency’ with no associated sanctions,” they pointed out.

The responses of the interviewees indicated that CCGs may choose to satisfy their public audiences rather than the government and possibly avoid “hard decisions in the face of public opposition,” they said.

Internal accountabilities were equally complex, and it was unclear what sanctions would or could be applied to general practices that transgressed the rules of their CCG, the authors emphasised.

“This early study raises some important issues and concerns, including the risk that the different bodies to whom CCGs are accountable will have differing (or conflicting) agendas, and the lack of clarity over the operation of sanction regimes,” they concluded.


Cite this as: BMJ 2013;347:f7501


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