Why we cannot afford to be pessimistic about CCGs

Clinical commissioning groups (CCGs) have a lot stacked against them. They have taken control of the majority of the NHS budget at a time when financial pressures are mounting and there is little hope of relief in the next few years. Some GPs have gone as far as to say they are being set up to fail.

The future of CCGs hinges to a large extent on the support they receive from local GPs. Clinical commissioning does not necessarily require substantial direct involvement from all or even most GPs. What it does need is widespread ‘buy in’, so that members feel a sense of collective ownership of their CCG and shared responsibility for its success.

This is particularly so in relation to the development of general practice itself. If CCGs are to play an active part in encouraging innovation and improvement in general practice – as our report argues they must – then all local practices will need to be part of this. CCGs will not be able to develop new community-based services or to improve the management of long-term conditions in primary care unless local GPs support these changes.

It is clear that engaging member practices will, at times, be challenging, particularly when CCGs have difficult decisions to make. Nonetheless, we found some grounds for optimism in our research. The extent of clinical involvement was generally felt to be improved relative to practice-based commissioning, and in some areas there was a growing sense of shared ownership and solidarity.

This was far from universal, however, and we also found evidence that CCG leaders are significantly more positive about the extent of member ownership than GPs who are not actively involved in the CCG. This is an important finding and illustrates that CCGs have a long way to go before they can be confident that they command the support of their membership.

The direct relationship with member practices is intended to be the defining strength that sets CCGs apart from primary care trusts and their predecessors. A core challenge for clinicians leading CCGs over the next 12 months is to convert the goodwill that exists in the GP community into active support and engagement.

They will not be helped in this by uncertainty over the future of CCGs. While we should be alert to the risks, few things will stop GPs from engaging with clinical commissioning faster than the suggestion that CCGs will not exist in their current form for much more than another two years. The danger is that those who predict the failure of CCGs, or who actively propose their dissolution, create a self-fulfilling prophecy and prevent CCGs from meeting their potential.

Given the energy and resources invested in their creation, and the need now more than ever for effective commissioning in the NHS, that would be an outcome we cannot afford. Distilling complex research findings into messages for policy can sometimes be a challenge. On this occasion there is one message which is simple to convey: CCGs must be given a chance to succeed.

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#40679 Mary Hawking
retired GP
none now

CCGs are faced with the same demands as PCTs: their most important objective is to keep in budget - which many PCTs found to be impossible.
Consequently, at the coalface of general practice no changes can be considered *unless they lead to financial savings*.
Take improved facilities to divert activity from A&E: freeing beds in an Acute Trust means more elective activity - at greater cost to the CCG.
Another method of reducing secondary care expenditure is to increase the number of "low priority" treatments - or increase the number of hoops GPs and patients have to jump through - lose impossible amounts of weight *before* referral without support, stop smoking, stop drinking, prove you are entitled to treatment (how do you *prove* that you are British if you've never had a passport?) - and all this on the admitted reason that it is a cost-cutting exercise?
In any CCG, there are likely to be differences of opinion about priorities between those tasked with delivering much more for much less and the front line trying to look after individual patients - which, after all, is supposed to be job of a good GP!

GPs have been beaten up by PCOs (Primary Care Organisations) about their prescribing and referral habits as long as I can remember: even if massively under budget in one area, any self-respecting PCO - including any CCG - can always find at least one area worthy of a beating.
How long can - or should - GPs as GPs - not as Members of a CCG from which they cannot resign - be expected to put finance ahead of care?
Because that *is* the logic of the H&SC Act.

#40687 Carolyn
Health Promotion Specialist
Brighton & Hove City Council

I am not pessimistic, I don't think many people are who think CCGs won't work and aren't expected to. We are realists, clear of eye and pure of broken heart.

#40698 Milton Pearson
Craven Community and Voluntary Service

The local perspective of the new CCGs is a key facet of the way these organisations work, one which to my mind is starting to bear fruit here in Craven. Already our local CCG has recognised the underinvestment Craven has endured over the years and is working to redress this in balance. As a working model we need to give the new CCGs a chance to 'bed in' to show their effectiveness. To this end they require more than the two years some people are suggesting, before another model is imposed on the service, one which is likely to be more centralised and impersonal. Most rational people know short-termism is both destructive and costly; in this day and age can we actually afford yet another NHS reorganisation?
Give localism and the CCGs a fair chance.

#40699 David Pencheon

I agree with Chris Naylor here. One key ingredient is Trust. All of us working in the health and care system need have sufficient trust in each other. There's no way that everyone can or need be involved in CCGs (or indeed in Health and Well-being Boards). However, we do need to trust those who ARE, that they are sufficiently informed, supported, and positive; and have the interests of the community (particularly those with less voice and choice) at the forefront - within the resource limits that exist. Regardless of what happens down the line, we must make the best shot of the hand we are dealt. Patients and public expect us, and trust us, to do no less. Without trust, things fall apart...

#40717 Bryan timmins
Northants healthcare Nhs trust

And if the CCGs like their various predecessors fail ? Will the executive finally accept that the internal market concept is a dead end in itself. There are surely simpler smarter ways of commissioning services than this. The way forward ? Nhs England has shown, with its delivery of multiple complex service specifications, what a national coordinated approach is able to achieve .

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