As clinical commissioning groups (CCGs) head towards authorisation, the constitutional arrangements that link member practices to the governing bodies of their CCG are taking shape.
Advice from Local Medical Committees (LMC) and the British Medical Association (BMA) has cautioned against signing a constitution without explicit dispute procedures and which lack a clear commitment to engage with the LMC.
This advice is understandable since the future livelihood of GPs now depends on membership of a CCG. But it highlights two challenges in the relationships between GPs and the governing board of the CCG.
First, by homing in on disputes, the formative discussions that are taking place between CCGs and their local GPs may be focused more on discipline and censure than on quality and improvement.
Nuffield Trust research into US medical groups with budgets found a common characteristic amongst the groups was a clear narrative that high quality, evidence-based care would drive financial efficiency and reduce costs. This approach defined the ethos of the organisations and was argued to contribute to their high performance.
It is the ethos of peer-led change and improvement that is more likely to protect patient services in tough financial times – emerging CCGs need to ensure their constitutions support this way of working
With reports in the GP press of CCGs proposing draconian sanctions for practices that are seen to underperform, GPs have good reason to be cautious about signing a CCG constitution.
But, it is the ethos of peer-led change and improvement that is more likely to protect services for patients in tough financial times and emerging CCGs need to ensure their constitutions support this way of working.
The second challenge relates to the nature of 'GP interest' in the post reform NHS.
The creation of CCGs, with compulsory practice membership and an obligatory role in re-shaping local services rebalances the individual and collective interests of GPs. There are clearly overlaps between individual GP goals and the core mission of the CCG to improve population health.
But as NHS financial pressures start to hit primary care (see for example this article by GP magazine), how will GPs balance the interests and sustainability of the practice they own and manage against population health needs and commissioning initiatives? What trade-offs will be needed between practice priorities and those of the wider health economy?
Numerous QIPP programmes – designed to maximise the clinical and cost effectiveness of care for populations – are predicated on transferring care out of hospital and into primary and community settings.
Reducing outpatient referrals and earlier hospital discharges require more to be done in general practice, and large scale service transformation plans will typically involve transferring selected areas of specialist care to up-skilled GPs.
Some of these changes will lie outside 'core general practice' – running an anti-coagulation clinic for example – and will need to be 'commissioned ' from appropriately qualified GPs. But expecting GPs to follow national guidance for common conditions such as dyspepsia before referring to outpatients is simply part of the job.
Tensions are likely to arise when several QIPP initiatives kick in at once and GPs face multiple additional expectations about ‘core general practice’ – on the back of managing tighter practice finances.
GPs will have to step up to the plate and develop new ways of working in a tough economic climate, just as those in other parts of the health service (and other industries) are having to do.
But what are the limits to this expectation and how can we define what they should be? How should Local Medical Committees represent the interests of individual practices when collective responses are increasingly required? These questions require detailed consideration to recast our collective understanding of stakeholder interests.
Many GPs still don't understand what clinical commissioning is all about, let alone how it will affect their patients and practices.
Forming CCGs without such debate risks creating resistance and standoff rather than creative thinking about how to respond to current challenges.
This blog is part of a series of occasional blogs from the Nuffield Trust’s resident GP commissioner. Nuffield Trust Senior Fellow Dr Rebecca Rosen is Vice Chair of Greenwich Health, the clinical commissioning group for the London Borough of Greenwich. She is also a GP in Woolwich, South East London.
This article has also been published on GPonline.com.