New research highlights concerns about the future role of GPs in commissioning healthcare

Changes to the way primary care is commissioned in England, waning levels of engagement from GPs with a formal role in Clinical Commissioning Groups (CCGs), and cuts to CCG management budgets means these bodies risk becoming unsustainable, according to two leading think tanks.

In new research published today, the Nuffield Trust and The Kings Fund argue that CCGs and NHS England will need to consider changes to the way CCGs attract and develop leaders, and policymakers will need to ensure they have adequate funding to fulfil their new roles.

The report ‘Risk or Reward?’, is the second of a three-part study by the two organisations looking at the development of CCGs, the doctor-led bodies established in April 2013 to plan and fund local health services. Based on a survey of 279 GPs, observations, interviews and reviews of board papers, the analysis tracks six CCGs selected to broadly represent those across England, looking at their development as membership organisations and their role in developing primary care.

The research comes as some CCGs prepare to submit detailed plans later this week to NHS England on ‘co-commissioning’ – the proposal for CCGs to commission GP and other primary care services in partnership with NHS England local area teams from April. This option is in addition to their existing responsibilities commissioning hospital and community care - primary care commissioning is currently carried out by NHS England.

While CCG leaders and GP members surveyed were positive about taking on an extended role in primary care, researchers found that the benefits of co-commissioning could be undermined by conflicts of interest within CCGs, constrained resources and strained relationships within CCGs and with NHS England in local areas.

• Almost half (47%) of CCG leaders surveyed did not feel they had the time necessary to fulfill their existing role in the CCG, and CCG leaders interviewed as part of the fieldwork questioned whether they had sufficient capacity to expand into primary care commissioning.
• While the majority of CCG leaders felt that conflicts of interest were being managed adequately, researchers highlighted examples of decisions where there was the potential for, or the perception of, a conflict having occurred. They point out that conflicts of interest are likely to become more frequent as CCGs take on new responsibilities for primary care.
• Few GPs felt that managing GP performance – something that contract management responsibilities under co-commissioning may lead to - was an appropriate role for CCGs.

The research also finds that there has been a significant drop in the numbers of GPs who reported being highly engaged in the work of their CCG, from 19% of respondents in 2013 to 12% in 2014. Within this, there was a 10% drop in the proportion of GP governing body members who reported being highly engaged.

Researchers also highlighted the challenge posed to CCGs in retaining GP leaders as many reach the end of their initial term of office and new, potentially more attractive roles emerge in the kinds of GP networks prompted by the Five Year Forward View.

Holly Holder, fellow in health policy at the Nuffield Trust and one of the report’s authors, said:

“Our research shows that the future of the clinical role in commissioning healthcare remains fragile. While CCG leaders overall are still highly engaged in their work, our fieldwork and survey revealed this is waning and there are some worrying signs emerging over strained resources – both time and money. CCGs are set to be stretched yet further as they adapt to new and expanded roles after 1 April, when co-commissioning takes effect - something that will test the resilience of GP members as they seek to manage inevitable conflicts of interest.”

Ruth Robertson, fellow in health policy at The King’s Fund said: 

“CCGs are still relatively new organisations which need to be given time to develop and flourish. In the run up to May’s general election, the NHS will be a key issue and its commissioning structure will likely be up for debate. Our research shows that CCGs have the potential to play a really important role in driving improvement in the health service, but to do this they are going to need the right resources and support, along with the freedom and flexibility to develop local solutions.”

The Nuffield Trust and The King’s Fund study outlines a number of key recommendations to CCG leaders and NHS England to assist CCGs make the transition to co-commissioning and ensure the sustainability of CCGs. These are: adequate funds to help CCGs involved in co-commissioning fulfil their new roles; a strategy to help recruit and retain GP leaders in commissioning; focused work to develop non-GP members of CCGS to mitigate against conflicts of interest; develop new ways to strengthen the membership voice in decision-making; and ensure clarity on the relative roles of CCGs and NHS England.