There has been much discussion since the announcement within the 2010 white paper Equity and Excellence: Liberating the NHS about the functionality of clinical commissioning groups (CCGs), the new bodies are now responsible for much of the design of local health services. Their remit will include purchasing elective hospital care, rehabilitation care, urgent/emergency care, mental health and learning disability services and most community health services.
The emphasis for the structure of the groups is that the groups will be led by clinicians. In an article taken from popular broadsheet The Independent from April 1 2012, the then Health Secretary Andrew Lansley urged clinicians to use their clinical expertise and knowledge to ensure NHS services meet the needs of patients, stating: “My ambition is for a clinically-led NHS that delivers the best possible care for patients. Politicians should not be able to tell clinicians how to do their jobs.”
A year on, the shadowing is over, CCGs have to stepped into the shoes of the now-redundant primary care trusts (PCTs). Playtime is over and its now time to step forward into the classroom, but in reality what does that mean?
By default, CCGs are member organisations. All GPs have to be subscribed to a CCG in order to hold a contract. Will enforced subscription really mean engagement and ownership?
History says probably not, after all PCTs and before that primary care groups (PCGs) were keen to encourage clinical participation.
Many practice managers will have claimed ‘backfill’ funding for releasing GPs time from our practices to support the plethora of primary care committees. Experience suggests that it will probably be the same GPs who were happy to lend their time and experience to support the management organisations that will take centre stage in the new CCG organisations.
However, while the faces may remain the same, the commitment doesn’t. Balancing a full-time role as a general practitioner alongside that of a CCG board member (for those actively engaged) is a demanding ask, not only for the GPs involved but for the practices too.
The last two years have required a great deal of flexibility from practices and GPs to support the evolution of the CCGs, with the formation of constitutions and strategic plans to establish. There has been a huge investment in time and a considerable amount of flexibility, often at short notice. Board member and lead clinical roles are of course funded, and either the practice or the participating GP receives an income for their time commitment which is generally on a sessional basis.
Flexibility however, comes at a price, and short notice meetings requiring GP attendance can cause disruption to practice life and to patient care that is not always covered by the sessional funding. The GP’s time may be backfilled, but what about the cost to the team in rearranging those appointments, or the cost to the patient that has waited two weeks to see their favoured GP? GPs are torn between their role within the practice and their commitment to the group, and their belief that participation is key to the appropriate commissioning of services for their patients.
Aside from the reorganisation of appointments and redistribution of work either among the team or to a locum, practices may find themselves struggling to maintain their support and engagement with the groups of which they are active members. Being regularly challenged with managing the void left by members of the team to attending yet another meeting will stretch their ability to remain engaged.
The problem is escalated because as well as member GPs, the team left holding the fort has a part to play too - reading essential documents that will feed into strategy and contributing to broader discussions at clinical engagement meetings.
If they don’t use their voices to convey the needs of their patients then the structure really has not fulfilled the expectation that is set out to achieve.
To enable commissioning groups to succeed, practices must be supportive of their clinical leads.
Anyone actively involved in the management of a clinical commissioning group must receive the backing of the whole of the partnership and involvement must form part of the practice business plan.
Active GPs should find a method of communicating discussions arising from their CCG work with their partners, while appreciating that they must remain relatively impartial as they are representatives of the entirety of their member practices, and must not put the requirements of their own practice first. That will be a challenge in itself.
In a recent article,1 Dr David Tooth, chairman of Rotherham CCG in South Yorkshire, claimed that he has the support of his partners, but noted that while locums can cover clinical work, they cannot cover the management responsibilities of being a partner. He has had to made compromises to manage his time between the practice and the CCG. Speaking about his role as a ‘clinical leader’, he states that if he didn’t do the clinical work, he “would be just another NHS manager”.
In conclusion, to enable CCGs to carry out their functions, practices must be fully supportive to enable them to work. They must be responsive and flexible to the needs of a fledgling CCG. They must be participative in its broadest form. Sitting on the fence really is not an option, as it will be the member GPs who know the requirements of their patients that can really make a difference to the services commissioned for our patients. Communication is key, and member GPs should use their clinical leads to ensure their voices are heard and that this time, NHS really is clinically led for the benefit of our patients. Sadly though the reality of delivering Mr Lansley’s vision will come at a cost, and in order for the benefits to be realised there will be a cost to the patient and a cost to the practice.