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Engaging practices

Engaging practices

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Health policy experts are tracking the progress of six clinical commissioning groups focusing on member engagement and practice development

Clinical commissioning groups (CCGs) and those leading them have made a remarkable journey over the last two years. To build new organisations responsible for managing £65 billion of public money in such a short period of time would have been a challenging task in the best of circumstances. In the current financial and political environment it has bordered on Herculean.

This is not the first time clinicians have taken responsibility for part of the NHS budget. Clinical commissioning has a long history, involving some successes as well as disappointments. But CCGs stand apart from their predecessors in terms of the scale and scope of the budgets they control, their status as statutory organisations and the legal requirement for all GP practices to be members.

If CCGs win the support of their local clinical community and operate as member-led organisations, we will be in truly new territory and have cause for optimism. If they do not, the risk is that the time and energy that has been invested in their creation will have achieved little more than a modest shift in power - and at the cost of considerable turbulence and instability.

The King’s Fund and Nuffield Trust are working together to follow the evolution of clinical commissioning groups in six case study sites from 2012 to 2015. They are annoymous to avoid undue attention and were selected to be representative of the different types of CCGs through the country. Our research focuses in particular on the relationship between CCGs and their members, and the role that CCGs could play in supporting general practice to evolve and grow - an issue which has received less attention to date than it deserves. Our research findings so far illustrate both the potential that CCGs represent and the considerable challenges they face.

Across our case study sites, we encountered a sense of energy in CCGs and an impressive level of commitment from those involved in leading them. The CCGs were credited with having brought local clinicians together in new ways and put in place more structure around existing collaborative activities between practices. 

However, we also found considerable differences of perspective between CCG leaders and other local GPs. In surveys of member practices in the six areas, only a third of respondents without a formal role in the CCG felt that their CCG was ‘owned’ by its members, compared to two thirds of CCG leaders. Less than 40% of those without a formal role felt that decisions made by the CCG reflected their views. And while almost 80% of CCG leaders reported that the formation of the CCG had improved clinical relationships between GPs, only a third of those without a formal role agreed.

A priority for CCG leaders will be to close these gaps and create a sense of solidarity and collective responsibility among member practices. This already exists in some CCGs, but is heavily influenced by the history of working relationships in the area and other factors such as the size of the CCG. If ways to engage members in the work of the CCG cannot be found, there is a risk that CCGs could repeat the history of diminishing clinical involvement that characterised many primary care trusts (PCTs).

One of the most significant opportunities that the new commissioning system presents is the potential for CCGs to play an active role in supporting quality improvement in general practice itself. Although CCGs do not commission primary care directly, they do have a legal duty to support NHS England in this, and this role will be vitally important if they are to achieve their wider commissioning objectives. 

It is widely acknowledged that new models of general practice are needed that allow GPs and other practice staff to take greater responsibility for care co-ordination, adopt more proactive approaches towards population health management, and support an expansion in the range of services available in the community. 

PCTs had limited success in supporting these kinds of developments. CCGs, on the other hand, could use their closer relationship with the GP community to provide leadership that encourages innovation and improvement in general practice. 

Given the importance of this agenda, the on-going lack of clarity over the division of responsibilities between CCGs and the area teams of NHS England is a cause for concern. There is widespread agreement that area teams will not have sufficient capacity or the local relationships needed to monitor or manage GPs’ contracts closely, and will be reliant on CCGs for their soft intelligence and their ability to influence.

However, the details of where these responsibilities begin and end, and how exactly these two types of organisations will work together is often still being worked out at the local level. Developing greater clarity on this must be a priority. 

Recent reports have suggested that CCG leaders are increasingly concluding that they will have a substantial role in primary care development, even viewing themselves as the de facto commissioner in some cases. Several CCG leaders in our research expressed some degree of unease about performing this role. Clinical leaders in particular were keen to avoid entering into any form of direct performance management relationship with their peers, and some were concerned about the scope of the responsibilities that NHS England might delegate to them.

Our research indicated that the majority of GPs believe that CCGs have a legitimate role in influencing their members in terms of referrals, prescribing, and other issues - even if they feel wary about the form that this involvement could take. Reconciling this role with the need to maintain clinical engagement and member ownership will be a delicate balance for CCG leaders to strike. Most CCGs are emphasising their intention to take a supportive approach, particularly through provision of comparative performance data to member practices, and by facilitating various forms of peer-to-peer dialogue.

These peer-to-peer relationships between member practices are likely to be among the most powerful tools at CCGs’ disposal. The power that CCGs have to harness these relationships is what could potentially set them apart from PCTs, and encouragingly, survey respondents in our research were optimistic that CCGs would be better placed than their predecessors to support improvement in general practice.

CCGs clearly face a number of significant challenges in building the relationships with their member practices that will be needed for them to succeed. 

Tight budgets make it harder for commissioners to invest in the kind of service improvements that will be needed to win the support of the local clinical community, and wider pressures on primary care place limits on GPs’ capacity to engage in the work of their CCG.

Nonetheless, our research suggests that for the moment at least, CCG leaders have a foundation of goodwill upon which to build. Converting this into active support and involvement is one of the most pressing challenges ahead.

The research report, Clinical commissioning groups: Supporting improvement in general practice? is available from the websites of The King’s Fund and Nuffield Trust.

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