Reshaping commissioning

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The introduction of clinical commissioning groups (CCGs) is one of the biggest changes under the new Health and Social Care Act. These new structures are intended to bring clinical experience into the heart of the commissioning process – but it's a big learning curve for everyone involved. With authorisation starting in October 2012, how ready are the CCGs to take over the mantle of primary care commissioning?

What's happening with clinical commisssioning groups?

'Most CCGs exist in some form now,' says Chris Naylor, 'but they're in very different positions. Some have grown out of pre-existing practice-based commissioning groups, so are able to push on with their existing work programmes, such as services redesign. But some of the newer ones have had to figure things out from scratch.'

Meanwhile many CCGs are taking a slightly different direction to the vision originally set out in the White Paper: small groups of GPs controlling very local services within their local area. Chris explains: 'We've already seen groups merging together to form bigger groups with bigger management structures.

'A Health Service Journal survey found that almost two-thirds of groups are putting a former PCT manager in charge rather than a GP. Some will be bringing in support from external organisations – many set up by ex-PCT staff – but some are employing specialist commissioners directly.' This has an inevitable impact on the relationship between clinicians and the services they commission.

How have GPs responded to the clinical commissioning groups?

The real test of clinical input will be the level of clinical engagement within each CCG. One GP who is extremely positive about the changes is Dr Gabriel Ivbijaro, chair of Waltham Forest Federated GP Commissioning Consortium, which was awarded 100 per cent delegation of budgets from 1 April 2012.

'I'm very excited,' he says. 'The new arrangements provide us with an opportunity to work in a way that hasn't been done before. As a family doctor, you understand the evidence but also the reality of services, and the demand – and you're able to bring all this together. I can bring my clinical acumen and leadership together in a holistic way to produce better outcomes.'

In Waltham Forest, the CCG is developing innovative ways to simplify services and improve access in an area facing many challenges, including higher-than-average levels of diabetes and chronic obstructive pulmonary disease.

Why is clinical involvement so important in commissioning health care?

For Dr Rebecca Rosen, vice-chair of Greenwich Health CCG – another CCG about to go through the authorisation process – these practical improvements form a key part of the CCG role.

'Part of the success of clincial commissioning depends on changing and improving primary care services,' she explains. 'There's been too little medical voice in strategic development to date – it's been too managerial.GP involvement will infuse the whole process with a different sensitivity to the frustrations, discontinuities and duplications that patients see a lot of, and to how services should be delivered.'

What lies ahead for clinical commissioning groups?

There are some inherent tensions in the GP commissioning model. One criticism sometimes levied is that those vulnerable groups that are less visible to GP surgeries, including people with severe mental health problems or people who are homeless, may not be on the radar of CCGs.

The government expects that most CCGs will be authorised by next spring, but it's not yet clear how likely this is. Until the remainder are ready to take on entire budgets, local branches of the NHS Commissioning Board will be picking up the responsibility.

But for those GPs who are highly engaged within CCGs, the new arrangements present an opportunity to use their expertise to shape the local health economy. 'Our weight and authority in the new arrangements is stronger,' says Rebecca, 'but it's changing all the time.' For now it's a case of 'wait and see'.

This article first appeared in Insight, a magazine produced by The King's Fund for the NHS Confederation Conference 2012.


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