CCGs were set up with the dual aim of bringing clinically led decisions to the fore when commissioning and planning care and to incentivise every GP to think about the cost of their consultation decisions when prescribing or referring. Did they succeed?
CCG leaders pointed to several common areas of success: creating a unified voice for primary care; improving pathways and patient care; and developing primary care, including establishing primary care networks (PCNs) in 2019.
A unified voice and primary care development
Our Healthcare Leader CCG evaluation survey, answered by 143 CCG leads and staff, found that 67% think CCGs were successful in making clinically led decisions, 71% think they were successful in increasing the primary care perspective and voice within the NHS and 66% think they generated clinical leadership. See box 1.
CCGs were given the lion’s share of the NHS budget with which they were to commission care for their local areas. This helped to adjust the playing field between small primary care providers and large acute providers, even if it did not level it. Having leadership from GPs was ‘wonderful’, said the chair of West Leicestershire CCG, Dr Mayur Lakhani. ‘We’ve never had it before. It was official, so that was really good.
‘I think when we look back, CCGs will be seen as the crucial element underpinning a clinically led NHS. I’ve just been in an ICS meeting, and it’s all about supporting the transition of clinical leads. About five or 10 years ago, that would have been managers sitting in a room – not because they didn’t want to [engage with clinicians] but because they didn’t know how to connect,’ adds Dr Lakhani, who has recently been appointed chair designate of the clinical executive of Leicester, Leicestershire and Rutland ICB.
Another powerful achievement of CCGs is the idea of general practice as a corporate entity. Leaders point to the establishment of PCNs and GP provider alliances, or a network of networks, as good examples of the creation of primary care as a more cohesive tranche of healthcare architecture.
Dr Lakhani explains that in Leicestershire there is a provider alliance of GP practices that have come together as one unit – which would have been ‘unheard of without CCGs and other enablers’.
‘GPs are now working together as practices and saying, “we’re a force to be reckoned with”,’ he says, and highlights that instead of 7,500 disparate practice voices there are now 1,200 PCNs.
‘Just imagine our power and might if we spoke coherently, which I think we’re getting to, because we’ve got a way of speaking, a common language – population health.’
Dr Joanne Watt, chair of Northamptonshire CCG, agrees that CCGs have been the ‘glue in the system’ through co-ordinating the Covid response, the vaccination programme, the development of PCNs and the GP board that was formed during Covid.
Speaking about the board, Dr Watt says: ‘It’s supported by the LMC and chaired by the LMC chair, but it’s so much more than the LMC. It incorporates three federations and the CD16 – which is what our PCN clinical directors (CDs) call themselves. It is going to be taking on the support of our localities as well,’ she says, and adds that this organisation will feed into the primary care representatives.
Of course, there are huge tensions in some areas between practices and CCGs. This highlights the division created by the commissioner-provider split, which we will explore later. But Dr Watt says her CCG worked hard to engage and advocate for practices.
‘It used to be that when hospitals got busy, an email arrived telling GPs to work harder and faster. I have changed that and I hope it sticks. Now, when hospitals are hot I phone the medical directors and ask “What are you hot with? What can we do? What could be different?” That’s one of the areas I’m most proud of. We’ve got a clinically sensible approach to surge. I hope that it continues [in the new system].’
Dr Agnelo Fernandes, clinical chair for Croydon CCG in south-west London, also says close working with the area’s key trusts has been a huge positive.
His CCG appointed a place-based leader across the CCG and the trust in 2018 with a memorandum of understanding that established joint board and committee meetings and joined their finances ‘at the hip’.
‘Before, either the CCG or the trust did well financially, but not both. The system was in deficit and commissioners and providers were not working together. Once we started working together, we had huge improvements in terms of quality, transformation, efficiencies and finance.’
In Croydon, investment was funneled into primary care for integrating general practice with the wider primary care and transforming pathways. Planned care was part of this, where there was a single point of referral to the local hospital, because ‘finance follows the patient’.
Referrals were reviewed before they were sent, and advice and guidance were available before they became mainstream policy.
‘In my practice we still have a peer review meeting every day, for all referrals that go into secondary care. We had a financial challenge, but we had a quality challenge as well. So all our other trusts have long waiting lists for client care, but ours is the shortest,’ he says.
Dr Neel Gupta, former chair of Camden CCG in north London, explains they worked on bringing GP practices together before PCNs.
‘We have taken an innovative approach to primary care commissioning in Camden. Ahead of PCNs, we brought together neighbourhoods and we set outcomes at neighbourhood level. It embedded joint working because we were collectively responsible for the outcomes of that population rather than just our own practice.’
CCGs set about designing new care pathways and leaders say that this work has ‘definitely’ improved care. See box 2.
Some 59% of our survey respondents thought CCGs had been successful or very successful at improving patient care, while just 15% felt they had not.
North East London CCG covers seven boroughs with very different populations. Its chair, Dr John Jagen, has numerous examples of his CCG’s successful innovations in primary care.
‘We’ve done really impressive stuff over the years, built on hardworking, professional clinical and care staff, looking at population-based health. We’ve also done a huge amount of work on social prescribing and holistic care plans, which is something North East London’s really leading on, the personalisation agenda,’ he says.
He highlights the diabetes care and treatment in Barking and Dagenham, which reduced the number of undiagnosed cases by more than 1,000, produced patient information on foot care in numerous languages and, during the lockdowns, carried out patient reviews in local parks.
In Redbridge, he says, there was award-winning work on atrial fibrillation. ‘This saw improvements in detection of heart conditions. We were recognised as the most improved London borough in terms of preventing strokes, and working collaboratively with our local hospital – Barking, Havering and Redbridge University Hospitals Trust. And as a result of this, the pilot was adopted by three of the boroughs.
‘Also we’re leading on a big piece of work for a new health and wellbeing hub on the former site of St George’s Hospital in Hornchurch, which is a massive win. We also aim to get a dialysis centre there,’ he adds.
Dr Stewart Findlay, chief officer for County Durham CCG, says CCGs have supported care closer to home and community services. They have also led on integration with mental health teams, the voluntary sector, local authorities and social care. He also says the CCG has improved access and ‘done a lot of work to support the urgent and emergency care system’ – something CCGs are often criticised for.
‘We have a liaise scheme in Durham. It’s like an enhanced service scheme, an incentive scheme, that moves a lot of testing out into primary care. It makes sure GPs do things like 24-hour ECG monitoring, ECGs, manage DVTs. We’ll do bloods on behalf of hospitals’ remote clinics in the community, a whole load of things. We’ve done so much to help and support secondary care as well as develop primary care as CCGs.’
Our survey found that 62% of respondents felt integration across social care, the voluntary sector and public health had been successful. See box 2.
Dr Watt says the fact that CCG clinical leads are also jobbing GPs helps smooth the path of patients as they can report back directly on problems as they move through the system.
She says her CCG has a better relationship with care homes through its frailty work and the PCN care home service.
‘Our relationship with care homes is different. They were left out of the system but they are where a significant proportion of our patients live. I am pleased with how they’ve developed. As a CCG we’ve done lots of education and upskilling, and I’m hoping care homes have become much better places for people to live,’ she says.
Dr Lakhani cites the end-of-life care in his West Leicestershire CCG as a success, demonstrated by the fact it was adopted by all 133 practices. Another success was improvements in management of long-term conditions.
Dr Neel Gupta, chair of the North Central London CCG finance committee, says: ‘We’ve done genuinely ground-breaking things in Camden. In particular, we took an early move towards value-based commissioning and outcomes-based commissioning. Now, a decade on, people are still talking about these things as novel concepts.’
Camden developed a diabetes integrated practice unit using an alliance contract with a lead provider, the Royal Free London NHS Foundation Trust and University College London Hospital NHS Foundation Trust (UCLH), with an outcomes component making up 20% of the contract, with the aim of getting everyone to work together. A similar outcomes-based contract musculoskeletal service still exists, with UCLH as the lead provider.
‘We were able to invest in that contract and get people’s interest. We needed money to get the Royal Free and UCLH to the table, but we also needed lots of engaged clinicians for the clinical relationships. Over the years, we’ve built a lot of relationships between GP leads and hospital consultants – a real success that allowed us to develop pathways and commissioning models that I don’t think would have happened in a previous era,’ he says.
Dr Gupta says Camden was ‘the highest performing area in the country’ when assessed against the NICE diabetes triple target, for blood pressure, sugar control and cholesterol management – an illustration of the CCG’s success in getting people to work together.
‘Even if your practice was doing well, you had to think about what your neighbouring practice was doing – so it drove up the overall quality,’ he says.
Of course, the opportunity to innovate and improve care depended on the financial picture of a CCG. Some CCGs started life with huge deficits – something that Dr Gupta is very aware of.
‘People’s experience of this will have varied massively depending on the financial picture they inherited. When we took over as a CCG from a primary care trust (PCT), we had a large surplus.
‘We were in the perfect position, where we brought clinical leaders to the forefront who had great ideas about what was working well, what wasn’t working well, how things might look different and how we might transform the system. And we had the money to invest to deliver that.
‘Of the five CCGs, [in North London] Camden and Islington had more money and the outer boroughs didn’t. So the GPs in Barnet or Enfield who were CCG governing body members had very different experiences from me in Camden.’
South of London, in Croydon, Dr Fernandes inherited a deficit of ‘around £46m’.
‘It was seen as a poisoned chalice and we could hardly get any GPs involved in the governing body, or anything really. But we turned the tide. We wanted to do something different. We wanted to focus on quality, to improve quality and services as a way of addressing the financial challenge.
‘We started off on a really bad platform, but that was a driver for change. By the time we finished the Croydon CCG we had an efficiency saving of more than £122m, with transformational quality improvements as well as financial efficiency.’ See box 3.
The evaluation survey highlights lack of funding as one of the major obstacles. Some 57% of respondents said a lack of funds to commission care was a major barrier to success, although respondents were evenly spread on whether they thought there was a lack of funds to run the CCG.
Dr Lakhani says the financial levers set up in the CCG system did not work. He says CCGs got into a lot of debt, because they ‘essentially ended up growing the acute sector’ while there were no levers to grow primary and community care.
‘Hospitals had incentives to increase activity. Primary care had incentives to reduce activity – and this is for the same group of patients. One finance team was saying: “Let’s do more, let’s admit more people, see more people”. The other side was saying: “Let’s reduce activity.” That wasn’t deliberate, but the commissioning wasn’t aligned. Basically we had a system that was broken and wasn’t working in a joined-up way for patients. I think there was a need for change.’
The majority (43%) of those surveyed agree that CCGs were successful in saving on costs. See box 4, above.
CCG leaders feel there has been an impact on the behaviour of GPs, making them aware of the cost of their referrals and prescriptions. Some 65% rated CCGs as successful in this area in our survey. See box 4.
Dr Findlay says that in Durham behaviours in the consultation room changed.
‘For a while our incentive scheme was partly based on each practice showing a balanced budget at the end of the year. That was their share of the budget for everything, so if they managed services in the community rather than referring to secondary care they would be incentivised for the reduction in hospital referrals and in the cost of our services into secondary care. That drove a real change in referral patterns. GPs saw many more people in their own surgeries. When PCNs and the Investment and Impact Fund (IIF) came in, we thought they were going to replace our service so we stopped. We also had contracts in place by then rather than payment by results.’
Dr Findlay says that Covid makes it difficult to tell if referrals have gone up since the end of the incentive scheme.
‘We’ve tried to put similar incentives into a block arrangement with primary care but my feeling is that the incentive has been taken away. I’ve heard GPs say they’re now not incentivised to stop referrals – so maybe we stopped it too soon.’
However, if CCGs had been an unmitigated success, there wouldn’t be a move to shake things up again. Our interviewees point to several common failures of the CCG structure – the commissioner-provider split, the failure to ‘move the dial’ on urgent and emergency care, and perverse incentives.
This biggest of these failures is the commissioner-provider split. This divided the GP workforce into two camps. The commissioners had the power and the budget and pushed the incentive schemes to drive efficiencies at practice level. But some GPs who focused on providing care felt that CCG GPs went into new shiny buildings and forgot their roots.
The commissioner-provider split was the clearest tension in the CCG structure. The Covid pandemic shone a light on the fact that much more can be achieved through collaboration.
Dr Findlay says: ‘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.’
Our survey 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. There was 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. See box 5.
Former chair of Brent CCG Dr Ethie Kong says the division CCGs created in primary care led to mistrust between commissioning GPs and providing GPs, and became a barrier to improvement. She is concerned that these tensions will not dissipate.
‘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. At the moment, there are PCNs, which do not have the same voice as CCG GP leaders. But 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. Why is there this divide?’
Dr Watt says it’s been difficult to develop a sense of shared outcomes, things that everyone feels are important for their populations. She also points to difficulties in translating the public health data into innovation for clinical services.
‘The way the finances have worked, it’s been about counting the number of procedures one does, even though they’re not necessarily the procedures that will produce the most health for our population.
‘If we look at an area like frailty, we should make sure people have the best lives possible, not that we do the most hip operations. We should be focusing on mobility, independence, satisfaction and happiness, rather than operations, which may or may not have improved people’s mobility, but are necessary in order to fund hospitals.
‘We’re now hopefully going to take a much more holistic approach to what our population actually needs for a dignified and appropriate old age.
‘I am optimistic about that focus on health inequalities, looking at Core20PLUS5, a national approach to tackling health inequalities. I hope we’ll start to get more of a focus on what is important from an outcome point of view, the shared proxy measures. And that, hopefully, this will allow finances to be moved more flexibly around systems.’
The impact of Covid on CCGs
Covid brought many things into sharp focus – who the key workers were, who the people in most need were, the disparities in society. It also showed that the way forward for the NHS was collaboration, not division, competition and financial penalties.
The internal market, which was lauded as the key driver for saving money in the NHS, worked in giving primary care leverage with large acute providers and in incentivising practices to refer less. But collaboration has won out as more beneficial to both the system and patients.
Dr Lakhani says: ‘The internal market is going because particularly in Covid, we found that the providers got together and said: “These are the services we need for the Covid emergency – set up these pathways.” We created hot hubs, and hot and cold wards in the hospital.’
Much of the leadership in the pandemic came from providers. But CCGs had a role to play providing clincial leadership and supporting PCNs as hot hubs were established and resources were shared.
Urgent and emergency care
Urgent and emergency care is often seen as a particular area of failure for CCGs.
Our survey showed a spread of opinions – with 32 % rating urgent and emergency care as successful, 26% neither successful or unsuccessful and 38% as unsuccessful. See box 4.
Dr Lakhani says: ‘I think we were overwhelmed with demand and weren’t able to really reshape the healthcare system. It wasn’t through lack of trying. But remember these are worldwide problems, and we didn’t have the powers to really change things.
‘We had payment by results, and there wasn’t an aligned financial framework and strategy. There is a new framework now for thinking about things. It’s detailed and complex, but basically, it rewards collaborative working.
‘I think we didn’t really move the dial on the big issues that would worry the Government and people – waiting lists, cancer diagnoses, urgent and emergency care, and A&E. But was it realistic to expect CCGs to do that? I think hopes were very high.’
However, our interviewees had a spread of opinions. Dr Findlay did not see issues with urgent and emergency care.
‘In North Cumbria we had an emergency care network. All our trusts, CCGs and ambulance service worked together to make sure urgent care worked across the region. How will an ICS create anything different from that? I think we were one of the most successful urgent emergency care networks,’ he says.
Urgent care remains a challenge for the system. The latest thinking comes from the Next steps for integrating primary care: Fuller stocktake report published by NHS England in May. It calls for an urgent care pathway in primary care to link all aspects of the service from 111 and urgent treatment centres to GP practices and pharmacies.
The report states the NHS should: ‘Develop a single system-wide approach to managing integrated urgent care to guarantee same-day care for patients and a more sustainable model for practices. This should be for all patients clinically assessed as requiring urgent care, where continuity from the same team is not a priority. Same-day access for urgent care would involve care from the most clinically appropriate local service and professional and the most appropriate modality, whether a remote consultation or face to face.’
Perhaps this latest idea will be the one that gets a handle on the issue of managing urgent care in the community.