CCG: friend or foe?

Friend or foe1Put yourself for a moment into the shoes of a GP; not an ambitious, management focused, media hungry go-getter, but a doctor who wants the best for his/her patients. Your list size is average, which means that around 1600 patients are registered with you, and depend on you to co-ordinate their care, and be their first point of contact, their main provider of care.

Do you happen to know how much the NHS spends on an average GP list each year? Using the back of an envelope (so the figures are approximate), I worked out that  in 2012, the UK NHS budget was close to £110 billion, which was available to look after about 60 million people; that works out at about £1800 for each person, which meant that for an average list, about £2.9 million was available. Scary isn’t it?

Now obviously, quite a lot of this was spent on fixed overheads like Public Health England, and redundancy packages for displaced managers, but let’s ignore these for the moment, because it’s always been the Government and ‘The Centre’ that have determined these. The important point is that since April this year, control of over two thirds of this budget has been handed over to CCGs, to spend on commissioning services for their patients.

The logic underpinning this move has been explicit since the 1990s: GPs co-ordinate their patients’ care, and their referral of these patients determines much of the activity in the community, mental health and acute sectors; so who better than these individuals to ‘own’ the resources associated with all this activity, and use their knowledge, common sense and autonomous professionalism to begin to move activity in ways that improve both the effectiveness and the efficiency of that care?

All the reforms of the past two decades or more have been moving towards this end. GP fundholding, GP commissioning, PCGs, PCTs, and now CCGs, all have been designed to wrest control of activity as much from politicians as from the large provider organisations, to stop them peddling their vested interests to the public (often through the tabloid media).

The logic of all the policies developed over this time (Working for Patients; ‘a primary care led NHS’, ‘the New NHS-modern, dependable’; Equity and Excellence: Liberating the NHS; to list but a few of the buzz phrases) have all been pushing in the same direction, albeit with different structures in place to make the policies happen.

So how does this link to the title of this piece? Are CCGs a Good Thing for GPs, or a Terrible Disaster? I started by pointing out that in theory, GPs each have the power to control the manner in which £2 million pounds or more should be spent on the care of their patients, so I’ll follow that up with two challenges.  The first is: who do you think better understands patient flows and needs: patients’ GPs, or middle managers based in whatever incarnation of health authority happens to be in vogue? Only GPs know what their patients’ medical needs really are and with the freedom to be innovative, they could probably think of all sorts of ways of doing things better, more quickly, in more user-friendly ways: it’s £2 million pounds, for goodness sake…

But my contrary second challenge is about strategy: £2 million may seem like  a lot to you and me, but it’s only a couple of trees in the enormous woods of the NHS; how do we a) maximise its impact and b) minimise the risks to individual GPs, their practices, and their patients? The strength of general practice lies in individual patient care.  If GPs are to be involved in planning and procuring services for entire lists, then they will need ways of working that offer economy of scale and provide insurance against unexpected events (imagine what a cluster of motorway crashes over a holiday weekend would do to the Trauma & Orthopaedics budget) without destroying the ‘can do’ spirit that has been so integral to their success over the past 65 years.

Where CCGs are genuinely ‘owned’ by their GPs, then the new organisations have great potential.  As in any successful corporate entity, individuals will need to accept that the needs of the group will sometimes trump their own local issues, and they will have to toe the corporate line a lot more often than they may have done in the past. However, they should then expect their CCG ‘corporation’ to offer support and act on practical suggestions often enough to show the practices overall benefit and maintain their loyalty. They could then be seen as ‘friends with teeth’, where the relationship needs constant effort and development, but where the gain (whether in terms of patient care, professional satisfaction, or even primary care development) justifies the pain.

However, if CCGs are either run in a top down fashion, or driven by political rather than care based priorities, then it will not take long for the cynicism to emerge; like the PCTs before them, such CCGs will quickly be seen as foe, whose actions are to be resisted and subverted.

In summary then, CCGs have the potential to be THE agent for change in the new world of NHS England, but only if their growth and development are carefully nurtured. The large scale leadership developments that seem to be emerging from the new Leadership Academy have never worked before, so it is hard to see how they will be more likely to succeed this time. What is needed is enough interest to be engendered amongst ‘working’ GPs to persuade them to invest some of their precious time and emotional energy in getting their show on the road, and make it a show of which they, and the entire NHS, can be proud.

And that won’t happen without effort or resources; but with the potential for every GP with an average list to really influence how £2 million is spent on his or her patients, isn’t that investment worth it?

This piece is based on an article first published in Pulse magazine on 24 June 2013

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