The launch of Integrated Care Boards (ICBs) sees the end of the purchaser-provider split described as a barrier to successful primary care provision in a report from Healthcare Leader.
The report CCGs: A post-mortem highlights that the split misaligned financial incentives and was a source of conflict in primary care.
The creation of an internal market within the NHS during the 1990s, which kept third-party payers organisationally separate from services was further boosted by the 2012 Health and Social Care Act which established clinical commissioning groups (CCGs) partly to incentivise efficiencies in primary care.
However, the shift to ICBs – which are responsible for allocating funding from NHS England – will see representatives from both primary and secondary care involved in planning and providing care.
The report included in-depth interviews with eight CCG leaders who revealed the commissioner-provider split was the clearest tension in the CCG structure.
Dr Stewart Findlay, chief officer for County Durham CCG, said: ‘We were encouraged by the system to work against each other. In the early days we were pretty tough with our providers, particularly our acute provider.
‘I think we went to arbitration twice with them and obviously that’s seen as a failure. But if you wanted to invest in primary care and community services, the money had to come from somewhere. It was a couple years until we got into a more balanced position with our providers and realised we should think win-win, not competition.’
The report – CCGs: A post-mortem – found that some CCG leaders suggested the division CCGs created in primary care led to mistrust between commissioning and providing GPs.
Dr Mayur Lakhani, chair of West Leicestershire CCG, said: ‘We had too many GPs who were either commissioners or providers, and there were conflicts of interest. Now, everybody is sitting round a table and saying: “Our population need is diabetes, obesity, mental health, how do we sort that out?”
Dr Neel Gupta, former chair of Camden CCG in north London, says that some of the hardest conversations he’s had over the last 10 years have been commissioning primary care. ‘They have been the most difficult and bruising’ he adds.
Dr Ethie Kong, former chair of Brent CCG, said: ‘If only the commissioners in primary care had worked better with the providers, we could have worked better with our community and secondary care colleagues…we’re all GPs. We’re all caring for our patients, wanting to commission good services for our patients, wanting to provide good service for our patients. We are all on the same side for our patients.’
Out-going CCG leaders hope that the new system will support the hoped for collaboration which came to the fore during the initial peaks of Covid.
Dr Lakhani, who has recently been appointed chair designate of the clinical executive of Leicester, Leicestershire and Rutland ICB, says: ‘Instead of having the purchaser-provider split, we now say “It’s all our job to do it”… To use a football analogy, you think about “what’s best for the country, rather than the club”.’’
The reports accompanying CCG evaluation survey of 140 CCG leaders and staff showed a spread of opinion on the relationships between CCGs and GP practices and trusts. Most respondents (44%) said the relationship with GPs did not pose a barrier to success but nearly a quarter (24%) said it was a major problem.
There was also a spread of opinion on whether relationships with acute providers were a barrier to success – 33% ranked this a big problem and 29% ranked it as no problem, which perhaps reflects the varied relationships around the country.
The latest shift in NHS architecture has been the root of some controversy within primary care, with some bodies claiming the demise of CCGs will weaken the GP voice.
Last week, Pulse – Healthcare Leader’s sister title – revealed that only GPs with PCN director experience will be eligible to apply to sit on ICBs in some areas of England, prompting criticism that LMCs were essentially excluded.
Read the new Healthcare Leader report, CCGs: A post mortem, on the end of the GP led commissioning era.