Analysis: How managers seized control of commissioning

GPs were meant to be given the keys to the NHS last April, freeing them to reshape it from the bottom up.

But a Pulse investigation 12 months on from the most fundamental shake-up of the health service in 60 years reveals GPs are still not in the driving seat. While CCGs have made some progress, those leading them complain they have been straight-jacketed by increasingly heavy-handed bureaucracy and central control.

Even GP commissioning enthusiasts admit it is difficult to see much difference between PCTs and CCGs, with many of the same managers as before seemingly ‘running the show’.

Contrary to Andrew Lansley’s vision, GPs are firmly in the minority on most CCG boards. Figures collected by the TUC-funded campaign group False Economy, obtained by Pulse, reveal that GPs represent only 43% of CCG board members overall, and are in the majority on just 29% of boards. NHS managers are now the second-most commonly represented group, comprising 21% of all board members, and 58 managers sit on more than one CCG board.

Dr James Kingsland, president of the National Association of Primary Care, says CCGs have struggled in the first year to enact the changes needed to transform the NHS.

‘Many of my colleagues are saying it is difficult to know the difference between the CCG and the PCT in terms of personnel, outlook, delivery style or process,’ he says. ‘How does transformational change occur in a system that looks very similar to the last?’

He adds that NHS England’s local area teams are behaving very much as if the previous structure had never been abolished. He says: ‘I hear a lot of CCGs who say they face their area teams a little bit like PCTs faced SHAs, and the reporting mechanisms have a similar feel to them – as opposed to being in partnership with one another.’

GP commissioners say NHS England, Monitor and others have been progressively exerting more authority over how they spend their budgets and their freedom to shape services. 

Commissioning leaders also claim that cumbersome rules around competition and conflicts of interest mean crucial decisions over funding in primary care are completely out of GPs’ hands. Data obtained by Pulse from 69 CCGs last September found that board members in 12 areas had had to leave meetings when key decisions were being made on a total of 23 occasions due to conflicts of interest.

The purpose of the proposed reforms is to give you and your colleagues in general practice the  responsibility to shape services to deliver the high-quality care patients expect and deserve

Andrew Lansley in a letter to GPs in September 2010

This lack of control has also filtered down to grassroots GPs, who feel even less engaged then they did a year ago. A Pulse survey on the eve of the April 2013 handover found that just 36% of GPs felt more involved in commissioning under CCGs than under PCTs. A year on, a survey asking 429 GPs the same question reveals that figure has actually fallen, to just 33%.

Dr Paul Roblin, chief executive of Berkshire, Buckinghamshire and Oxfordshire LMCs, says this is a genuine concern: ‘GPs feel increasingly less involved in CCGs. Month by month, CCGs feel less like bottom-up organisations and are becoming more like the old PCTs, with strong managerial diktats.’

CCGs, for their part, tend to blame grassroots disengagement on the restrictions placed on them by NHS England. For example, NHS England has insisted that CCGs contracting providers, including GPs, must use the 210-page NHS Standard Contract template. This means practices bidding to provide the same enhanced services they have always historically provided must now appoint a ‘counter-terrorism lead’, for example.

Another example is Section 75, the controversial clause that compels CCGs to put services out to tender unless they can prove the services can only be delivered by one provider. Dr Krishna Chaturvedi, a GP board member at NHS Southend CCG, says: ‘CCGs are indeed hampered by NHS England, all the time. They are, of course, the same people who were running the show before. There is no freedom for the CCG. It is still centrally driven.’

A survey of 273 commissioning leaders by Ipsos MORI on behalf of NHS Clinical Commissioners last December found that only 14% of respondents agreed with the statement that the national team at NHS England enabled them to do a great job – compared with 38% who disagreed.

In this month’s Big Interview, the interim president of NHS Clinical Commissioners, Dr Michael Dixon, warns the top-down tendencies of NHS England and the powerful voice of secondary care mean general practice is still very much ‘bottom of the pile’.

He says: ‘It is has been a good year in that CCGs have been achieving. However, have they been given their wings properly? The answer is no, as they are still constrained by a system designed for a centralist grip, which is secondary care dominated and on the whole does not take account of general practice at all.’

Despite the criticisms, though, there remain glimmers of hope. It was CCGs – after discussions with area teams – that were behind the suspension of soon-to-be retired QOF indicators in several areas in the first three months of this year. The financial performance of CCGs has also been impressive, with only 24 facing deficits in 2013/14, despite a number of surprise bills having been thrown their way.

And although a number of large contracts have been put out to tender, the widely predicted mass expansion of the private sector in the NHS has not materialised – yet.

Dr Steve Kell, co-chair of NHS Clinical Commissioners and chair of Bassetlaw CCG, insists CCGs can make the changes the NHS needs if they are freed from central control.

‘What CCGs need is clarity and the ability to make commissioning decisions around the patient, not around regulations,’ he says. ‘We don’t feel hampered – but we must have freedom to innovate.’