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Feature: Getting better

Feature: Getting better
17 March 2014

That improvements in general practice are needed is not disputed, but how they should be driven is still much discussed
Who is responsible for improving the quality of general practice in the new look NHS? Clinical commissioning groups (CCGs) are largely getting on with it, despite a lack of clarity over their role, the roles of GP contract-holders (NHS England), and the revamped Care Quality Commission (CQC). 

That improvements in general practice are needed is not disputed, but how they should be driven is still much discussed
Who is responsible for improving the quality of general practice in the new look NHS? Clinical commissioning groups (CCGs) are largely getting on with it, despite a lack of clarity over their role, the roles of GP contract-holders (NHS England), and the revamped Care Quality Commission (CQC). 
CCGs have a statutory duty to support improvements in general practice. It is also crucial to achieving their wider aims of delivering more integrated and better NHS services. Yet CCGs have no direct authority over their member practices, and the responsibilities that lie with them and those that lie with NHS England have never been clearly defined. CCGs have little in the way of incentives available to influence their member GPs: NHS England controls the primary care budget as well as the GP contracts, and any money CCGs direct towards their member practices risks accusations of a conflict of interest. 
In the absence of any clear policy in this area, The King’s Fund attempted to define the different and overlapping roles of CCGs and NHS England in its 2013 report, CCGs: Supporting Improvements in General Practice. It placed things like ‘fitness to practice issues’ and ‘clear failures to deliver the GP contract’ within NHS England’s remit, as expected. ‘Persistent underperformance’ and ‘contract compliance’ issues were seen as areas for collaboration between NHS England and CCGs; and finally ‘practices not performing as well as their peers but within the bounds of their contract’, and ‘looking in detail at variation, e.g referral rates’ were seen as solely the responsibility of the CCG. 
This roughly matches up with what CCGs perceive is expected of them, what NHS England wants CCGs to do, and what grass-root GPs want to see happening. The King’s Fund report surveyed 73 GP leaders and staff across six CCG areas, and found that 80% of respondents thought CCGs should have a role in monitoring and influencing the clinical performance of member practices. NHS England’s deputy medical director, Dr Mike Bewick, has advocated a ‘co-commissioning approach’ where CCGs influence member practices to keep up quality and also join in discussions about the design of primary care services. 
Phil Moore, deputy chair of Kingston CCG, says that commissioning groups have already looked at ways to influence member practices and new services outside of the core GP contract, and are clear their role is not to inspect or command GPs. “We are not the 
performance managers of GPs. Improving quality is about influencing people, talking to them about what change is required and how it will improve services.
“We will work in partnership with NHS England, it is a mutual thing. We are not going to be the police or spies for them, but we would certainly talk to them if we have concerns.”
Bewick reassures CCGs that they will not be expected to put sanctions on failing practices, or do any type of ‘policing’ role. 
“There is always a group that are doing well and improving, a group that could do better and just need the data to know where to improve, and then there are those below a certain line who will fall under our remit, where we go in a look at whether there are ways we can support them or whether those services will be best provided by someone else.”
Yet there are already signs of mission creep for CCGs. In many areas they are apparently doing most of the ‘co-commissioning’ work supposedly under the remit of NHS England. A recent survey by NHS Clinical Commissioners of 273 senior CCG staff found just 19% felt NHS England was an effective commissioner of primary care, and The King’s Fund’s report warned that NHS England area teams clearly do not have sufficient capacity to understand individual practices’ performance. 
This has inevitably led to renewed calls for CCGs to be allowed to commission primary care themselves. Many CCGs seem to be already in charge of commissioning general practice, says Julie Wood, director of NHS Clinical Commissoners. CCGs are doing it “by default” in some places “because NHS England aren’t”, she says, adding that officially delegating primary care commissioning to CCGs wouldn’t require any legislative change. NHS Clinical Commissioners are currently consulting on how joint committees from CCGs and NHS England could commission primary care – with responsibility “technically delegated” by the statutory body (NHS England) to that committee.
“It really doesn’t matter that CCGs don’t hold the contracts for practices –it’s not such a bad thing. We can do all the good and positive support work and when you get a practice that is not responding at all you hand it over to NHS England,” says Wood. 
“It would be good if we could commission primary care properly, allowing us to commission services right across the pathway,” says Moore. “The only way you can enhance the patient experience throughout their care, from primary to secondary and all the way back, is if we commission all the services.”
Conversations “are already being had” about how NHS England’s area teams can delegate commissioning responsibility to CCGs, he says, effectively bypassing the legislation that says they can’t. “It depends on the closeness of the area team and CCGs – some are closer than others.”
In the meantime, the division of responsibility between the two organisations remains uncertain, and CCGs have a delicate job to do: How to exert pressure on practices to improve in a GP-led, non-bureaucratic way? A range of performance mechanisms are available to CCGs, mostly processes referred to as ‘soft governance’: training, support and group discussions. Some financial incentives are available, such as enhanced services that pay practices to monitor prescribing or referral patterns or attend CCG meetings. 
Speaking to CCG leaders, ‘peer review’ is considered the best way of subtly influencing practices to improve. Peer groups bring various practices together regularly – meetings not only help clinical staff learn from each other, but encourage a form of peer pressure where staff want to improve their performance in comparison to others. 
Some CCGs, such as NHS Dudley, have appointed a retired GP who knows the area well purely to engage with and visit practices, while other CCGs actually send a member of staff to work in practices that are underperforming. High performing practices can be asked to buddy up with poorer practices or offer training to those who are struggling. Details are important too – such as having all data and documents from CCG meetings easily available to all practices, like Greater Preston CCG’s tailor-made website SharePoint. 
Bewick describes “good examples all over the country” appearing independently of NHS England’s work. “Lots of work has been done with federated models of practices working together. No CCGs are contracting their practices, they are just helping them and working with them”.
Wood says many of the quality metrics and tools available to CCGs are in reality no different to the scorecards used by PCTs – but because they are developed with member practices, they are more likely to be useful. “Its about ownership – you are more likely to respond to something if you have chosen it.”
Practices are, in many areas, bound to improving quality and addressing poor performance as part of their CCG’s constitution. And if worst comes to worst CCGs can, of course, apply to NHS England to have a practice expelled from the group, effectively putting the practice out of business. 
Yet without formal, contractual arrangements like PCTs had, smart CCGs have figured out that the most important thing is to have genuinely engaged member practices. A structure that encourages shared ownership and unity among practices has been key to practices working together to raise standards in Kingston, says Moore. 
“We work very hard to engage practices,” he says. “The council of members is the CCG; they could pull the plug on the governing body if they want to. The area has a history of GPs working well together. That was achieved over a long period of time and through a lot of hard work, through a series of GP leaders getting out there and talking to people.”
Nuffield Trust health policy fellow Holly Holder, who co-authored the Kings Fund report above, says surveys reveal that CCGs do have GPs’ support when it comes to their role in improving quality, but they must ensure they do not lose their legitimacy as member organisations. 
“There are a lot of areas GPs think are legitimate spaces for CCGs to move into – prescribing, referring, other clinical behaviour. I think what’s important in these membership organisations isn’t necessarily the performance aspect, it’s how well the CCGs is representative of its members and how decision-making is made. Remember it is a compulsory membership organisation, so for it to seem truly democratic and representative, and to have all practices on board, all lines of communication need to be working properly.”
Yet there are worrying signs of a disconnect between CCGs and their member practices. The King’s Fund report found 66% of those who led CCGs felt it was ‘owned’ by their members, yet only 35% of those without a formal role agreed; 81% of CCG leaders felt their decisions reflected the views of their members, only 38% of those without a formal role agreed. “If this disparity grows wider over time, CCGs risk losing their connection with grassroots GPs,” the report’s authors warn. 
This, it seems, is the dilemma in a nutshell. Clinical leaders are keen to support practices and avoid the performance management style that characterised the PCT era. Yet there are signs that in some areas they will be forced to do more of the gritty quality improvement aspects no doubt originally intended to be done by NHS England. Challenging poor performance while maintaining member unity and ownership will be a delicate balance for CCG leaders to find.

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