CCGs vary widely in how well they deliver healthcare, new measure showsBMJ 2016; 354 doi: https://doi.org/10.1136/bmj.i4615 (Published 23 August 2016) Cite this as: BMJ 2016;354:i4615
New indicators show that primary care clinical commissioning groups (CCGs) in England vary widely in their ability to deliver healthcare equitably to rich and poor people.
Some inner city areas, such as Tower Hamlets in east London, have done well on the new measure, while others, such as central Manchester, did poorly. A large gap could also be seen in affluent areas, with south Cheshire performing relatively badly while east Surrey did well.
The Centre for Health Economics at York University devised the measure, which has now been adopted by the NHS in England as one of the tools it uses to assess and improve the performance of CCGs.
To make the comparison the York team needed a marker that enabled CCGs to be compared on how well they delivered healthcare to their populations, regardless of how large the underlying discrepancies in overall health were. This was a measure not of health but of healthcare.
They chose a measure that was in the capacity of the CCGs to deliver: the numbers of emergency admissions to hospital of patients with long term conditions such as dementia, diabetes, and respiratory and cardiovascular diseases. The better the primary and outpatient care, the lower the number of such admissions. The data came from hospital episode statistics.
To eliminate underlying differences in health status the measure used the rate of such admissions per 100 000 population, rather than the absolute number, and compared the rate in wealthier and poorer parts of the CCG area. As a national average, the difference in admission rates between the richest and poorest areas was 927 per 100 000 in 2015-16.
CCGs with a higher figure did worse than average, while those with a lower figure were better than average. In Central Manchester, the worst rated CCG, the figure was 2136; in Fareham and Gosport, the second best rated, it was 109. (The very best was City and Hackney, but there the figures may have been distorted by the atypical population, with a high prevalence of private care among wealthy dwellers in the City of London.)
The measure enabled each CCG in England to be compared against the national average and against the average achieved by the group of 10 CCGs most similar to them. The York centre has produced a list of the 10 best and 10 worst CCGs, all of whose scores were appreciably different from the national figure and from the average of the 10 most closely matched comparator CCGs (table 1⇓).
The York team’s lead investigator, Richard Cookson, said, “Reliable information on healthcare inequalities is currently scarce. National monitoring focuses on the average patient, and little attention is given to local monitoring of healthcare inequality. These indicators could be used to help managers learn quality improvement lessons, to help regulators and others to hold the NHS to account, and to help inform the public about healthcare inequalities within their local area.”
In England as a whole in 2015-16 there were over a quarter of a million “excess” admissions to hospital. Ruth Passman, deputy director for equality and health inequalities at NHS England, said that this excess imposed large and rising costs and raised important concerns about social justice.
She said, “For the first time, NHS managers can now find out how well their local CCG area is doing in tackling these inequalities, compared with similar CCG areas, and see how these inequalities are responding to local healthcare initiatives. This will help NHS managers learn about the best ways of reducing costly health emergencies associated with social deprivation.”
However, Mark Spencer, co-chair of the New NHS Alliance, which represents providers of community health services, said that the York analysis was too simplistic. He said, “[The higher number of people from deprived areas admitted to hospital] is not about worse treatment by GPs, it’s about the significant and complex health needs of those communities, including a higher prevalence of long term conditions and combined physical and mental health issues. Areas of high deprivation require more resources to achieve the same outcome as others, yet the reverse is happening.”
For 2016-17 and subsequent years NHS England has been introducing a new CCG Improvement and Assessment Framework, of which the new measure is part. Members of the public can discover the measure applicable to their own CCG through an online tool accessible at www.ccg-inequalities.co.uk.