The NHS has developed a complex machinery to hold both providers and commissioners of NHS services to account – a machinery that has become even more complex with the advent of 44 sustainability and transformation partnerships (STPs). This report draws on analysis and insights from the current system, and explores the challenges and opportunities presented by STPs for accountability in the NHS.
It reflects on accounts given in 13 interviews by senior CCG leaders and NHS England policy-makers, whom we spoke to in September 2016. We also draw on discussions at the learning networks that we established for leaders in providers and commissioning organisations; and on evidence from research and evaluations of former commissioning structures in England.
We also explore how commissioners and providers respond to different approaches to accountability and performance management. We then consider the implications of this learning from current and past experience for the future development of STPs, accountable care organisations and accountable care systems.
• Accountability arrangements in the NHS are complex, and experience shows that the tension between separate accountability arrangements for commissioners and providers magnifies that complexity further.
• Furthermore, performance management systems for CCGs are not well designed to capture those measures that are meaningful, measurable and within the direct influence of CCGs. Nor are they implemented consistently across the country.
• Despite NHS England policies to devolve more power to the local level, some leaders still felt a lack of control and autonomy over their organisations, particularly around the ability to set strategic direction.
• Leading a CCG through this period of change for commissioning has been difficult in the context of a lack of certainty and clarity about the future role of CCGs and what this means for their staff.
• At a time of extreme pressure on the NHS as a whole, these issues, coupled with an apparent lack of structured support for CCG leaders, have led to significant stress for those individuals.
• The majority of STPs are still developing the blueprint for their governance arrangements. These will have significant consequences for all the commissioners and providers involved – and will need to reflect the ways in which the STP and the organisations that form it are held to account.
• The recommendations we make as a result of our findings are addressed in the National Framework for Improvement and Leadership Development, published almost a year ago. As we approach the anniversary of that publication, we look forward to seeing NHS England and NHS Improvement set out the changes they have made as that framework is implemented, and to hearing the response to that from our networks of CCG, trust and STP leaders.
Holder H and Buckingham H (2017), A two-way street: What can CCGs teach us about accountability in STPs? Research report. Nuffield Trust.