Why we cannot afford to be pessimistic about CCGs

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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.

Comments

Mary Hawking

Position
retired GP,
Organisation
none now
Comment date
25 July 2013
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.

Carolyn

Position
Health Promotion Specialist,
Organisation
Brighton & Hove City Council
Comment date
26 July 2013
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.

Milton Pearson

Position
CEO,
Organisation
Craven Community and Voluntary Service
Comment date
31 July 2013
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.

David Pencheon

Position
Director,
Organisation
SDU
Comment date
31 July 2013
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...

Bryan timmins

Position
Consultant,
Organisation
Northants healthcare Nhs trust
Comment date
07 August 2013
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 .

Ingermar Peter…

Position
https://twitter.com/IngermarTurner,
Comment date
13 January 2017
Optimal performance and efficiency are probably better placed in a factory environment than in a clinic because in factories it is machines that do the work. There is no point turning the doctor into a machine for you will take away all of his job satisfaction. The doctor needs to feel a sense of job satisfaction and that the responsible decisions were his. I get the impression that CCGs are stealing the glory.

Further, when you take power out of society in order to create an authority it is important to ensure the efficiency of the structure you create. In other words, the power should be returned to society for the benefit of all and not hoarded to glorify the managers.

People who rarely become ill are paying for the NHS. Their payments take the form of an insurance so should they need medical assistance it will be available and delivered. The key word here is paying. It refers to an accountable transaction. However, the true worth of money is intangible. It is what provides quality and value. This is a spiritual entity. Now, if there is a power struggle going on between CCGs and GPs because there are discrepancies that are not being resolved, that conflict will ultimately detract from the doctor's satisfaction. Provision of healthcare versus management of commissions. Doctors are likely more affective personalities whereas managers, more cognitive. This is at the core of the problem. Care versus efficiency and cost.

May I say, the supreme question to be addressed here is why are so many people making demands upon the NHS? The answer can only be found in an examination ( a clinical examination) of the general economic policies of the government. Inequalities; job shortages; relative poverty and the way people are reformed and corrected when they err. All create ill health. We should pay more attention to preventing ill health and strangely enough that has nothing to do with the NHS. ( I am not a doctor) Best wishes from IPT

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