It is a year since most clinical commissioning groups (CCGs) took on a greater role in commissioning primary care services. NHS England reports that over this time, co-commissioning arrangements have helped to support local decision-making, enabled a more joined-up vision for primary care, increased clinical leadership and improved relationships between CCGs and local GP practices.
The conclusions from our survey of GP practices in six CCGs, carried out with the Nuffield Trust, are somewhat less rosy. Encouragingly, most CCG leaders were positive about the new co-commissioning responsibilities they have taken on. However, responses from GPs not directly involved in commissioning look rather like a collective shrugging of shoulders, with most feeling neutral about the development. Overall, four in five GPs said they had not yet noticed any changes as a result of co-commissioning. In part this may reflect wider apathy towards commissioning and GPs’ limited awareness of the new roles CCGs have taken on.
Some of the concerns raised by CCG leaders we have worked with over the past year shed light on why co-commissioning appears to have delivered little so far. The transfer of responsibilities (and the personnel that go with them) has generally been slower and more complex than originally envisaged. Although CCG leaders largely welcomed the principle of co-commissioning, they have been frustrated by the failure to provide extra resources to support the new responsibilities and by the fact that CCGs are being asked to take on these functions at a time when their running-cost budgets are decreasing year on year.
A few respondents highlighted the potential opportunities, with some GPs observing that communication between GPs and commissioners had improved since responsibilities transferred from NHS England to their CCG, or that discussions around performance now had a more local character. However, others reported that there was a growing burden of targets and performance measurement by commissioners – illustrating the fine line that CCGs have to tread in attempting to bring about improvements in primary care without alienating their member practices.
A key concern among the GPs who felt negative about the introduction of co-commissioning (about one in four of those surveyed) was the risk posed by conflicts of interest. GPs in this group were significantly more likely than others to say that arrangements in their local CCG for managing conflicts were not effective. The challenge for CCGs and NHS England is to ensure these arrangements are robust – and seen to be robust – without undermining the very reason for establishing CCGs in the first place, namely, to increase clinical leadership in commissioning.
In 2015 we argued that the potential benefits of giving CCGs a greater role in commissioning primary care could be compromised by conflicts of interest, reductions in CCG running-cost budgets and strained relationships with local GPs. One year on, it is clear that these issues are as alive as ever. Further, implementing co-commissioning successfully has become even more difficult as pressures on GPs escalate. Some GPs responding to our survey cited increasing pressures in their clinical work as a reason for disengaging from CCG activities. Research to be published by The King’s Fund next month will shed light on the nature of these pressures and the options for addressing them in future.
It is perhaps unfair to judge the success of the co-commissioning policy after only a year, particularly given the time required to implement the changes. And it should be said there is some good news from our research – CCGs appear to be bedding in as organisations and having increasing influence over primary care, including a positive impact on relationships between GP practices. But with many CCGs set to take on greater co-commissioning powers in the coming year, it is of some concern that they are doing so without a groundswell of support from local GP practices.