Take care CCGs: it was the conflict of interest that tripped them up last time

In the past couple of weeks, ‘co-commissioning’ has emerged as the latest solution to the problems in primary care. In a recent speech, Simon Stevens, Chief Executive of NHS England, announced plans to allow clinical commissioning groups (CCGs) to ‘co-commission’ primary care services with the NHS England area teams that are responsible for GP contracts and primary care strategy. This, he said, would give patients, communities and clinicians ‘more clout’ in deciding how local services are developed, at a time when NHS finances are severely strained.

The detail behind his proposals was published on Friday, and included some important information about how these arrangements will work. First, co-commissioning is optional: CCGs that are interested in an extended role must submit an expression of interest – either alone or as a group – by 20 June. Second, this is not a one size fits all approach: CCGs can choose from a spectrum of commissioning arrangements that include fully delegated functions, joint decision-making or simply increased involvement in the current decision-making process. Third, not all primary care commissioning is up for grabs: community pharmacy, dental services and eye care will stay with NHS England; as will registration, revalidation and the appraisal of GPs. However, all other areas of primary care commissioning are open to joint arrangements.

It’s important to remember that primary care commissioning is not uncharted territory for CCGs. The Health and Social Care Act gave them a statutory duty to support quality improvement in primary care, and they already commission out-of-hours GP services. They also have delegated responsibility for designing locally commissioned services (previously called local enhanced services) that pay GPs for services beyond their core contract. Our recent survey of GPs showed that so far, CCGs have tended to take a facilitative approach to primary care development – encouraging practices to discuss comparative performance data and organising group education sessions for their members. However, the new plans go far beyond this. CCGs can elect to take on responsibility for developing their local primary care strategy; negotiating, managing and enforcing local contracts (eg, Alternative Provider Medical Services, Personal Medical Services); financial management; and taking decisions on new local providers and practice mergers.

This extended role in primary care could bring many potential benefits. At a time when general practice is struggling to meet growing demands from patients it feels crucial for CCGs to use their leverage as membership organisations to encourage GPs to work in new ways, at scale, and in multidisciplinary teams to develop primary care services fit for our future needs. The King’s Fund argued for the development of these new models of provision in our recent report on family care networks.

However, an extended role in primary care comes with risks. Maintaining close links with GP members will be essential for CCGs hoping to drive real change in primary care. At the same time, if CCGs take on responsibility for policing their colleagues, good relationships may be hard to preserve. Research published by The King’s Fund last year showed that, at the time, CCGs were reluctant to take on a performance management role with GPs for exactly that reason.

These new responsibilities shine a light once again on an issue that has plagued CCGs since their inception – the conflict of interest faced by GPs who are buying services from themselves and potentially managing their own contracts. CCGs looking to take on greater responsibility for commissioning primary care services would be wise to look back on the experience of GP fund-holding. That experiment in GP-led commissioning in the 1990s was undermined at least partly by public outrage at claims of GPs lining their own pockets. CCGs must demonstrate that they have clear, robust governance processes in place that show NHS spending decisions have not been influenced by vested interests, to avoid challenges from providers and the public.

I have spoken to CCGs that are actively trying to address the conflict of interest issue. They are using their lay members to scrutinise plans and ensure probity and they routinely declare interests at the beginning of meetings and stand down from decisions in which they have vested interests. But will this be enough? If all the GPs have left the room, where is the clinical involvement in commissioning?

Perhaps one solution is for CCGs to focus on pathway design and strategy, while the area teams and, potentially, commissioning support units retain responsibility for the mechanics of the procurement and contract management process – allowing primary care to reap the benefits of CCG involvement without the potential pitfalls. Over the next few weeks, as CCGs develop their co-commissioning plans, the appropriate division of these responsibilities will be an important balance to get right. And, in the run up to the next election, as the new NHS structures are put under even greater scrutiny, ensuring conflicts of interest are managed robustly will be key to the legitimacy and on-going sustainability of the CCG model. If they manage to do this successfully, their move into co-commissioning could bring a much-needed boost to the primary care sector, as it seeks to reshape itself to meet our current and future needs.

With contribution from Beccy Ashton, Policy Manager

This blog is also featured on the HSJ website

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#42091 David Buck
Senior Fellow, Public health and health inequalities
The King's Fund

Ruth, great blog, conflicts of interest are clear issues here. For me, one of the disappointments for me of NHS England's recent (now clearly waning) monopoly over commissioning primary care is the lack of use of that immense power to commission and hold to account for inequality reduction. The Department of Health, NAO and others have done all the analysis to show how systematic, scaled up interventions in primary care will speedily narrow inequalities in life expectancy between deprived and wealthier areas. The power that NHS England had to alter that through its monopoly, was not used to tackle that. Now it looks like the opportunity is lost, I hope that CCGs will do a better job.

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