Analysis: What power will GPs really have in the new NHS?

1 April 2013 will mark the first day of a much vaunted new era for general practice. GPs in England take on statutory stewardship of more than £60bn of NHS funding – and with it, in patients’ eyes at least, accountability for tough decisions on treatment rationing and hospital reconfigurations.

But how much power will GPs really wield in the new NHS?

A Pulse snapshot survey of 303 GPs, conducted on the eve of the handover, would suggest it’s a lot less than ministers have claimed.

CCGs are in place, but GPs are beginning to realise that their power has its limits. All practices are members of a CCG, but many say they have found the experience little different from their involvement in PCTs.

Even previously enthusiastic CCG leaders are losing faith with the ‘command and control’ approach taken by the NHS Commissioning Board, recently rebranded as NHS England.

Grassroots engagement

Ever since then-health secretary Andrew Lansley surprised many with his bold vision of a health service ‘run from the bottom up’ in a July 2010 white paper, the Department of Health has insisted GPs are supportive of the reforms – using the formation of CCGs across the country as evidence of grassroots engagement.

But Pulse’s survey of 303 GPs reveals the majority (55%) do not feel any more involved in commissioning decisions under their CCG than they did under the PCT. Just 36% do feel more involved.

Strikingly, one in five GPs said they had not signed their CCG constitution, raising questions over the depth of GP engagement at CCGs. Of the 48 GPs who said they had not signed their constitution, the vast majority said they had not been asked to, while three even said it had not been finalised or had only just been circulated in draft form.

A further 20% did not even know whether or not their practice had signed a constitution.

At the extreme end of the scale, the board has even forced two practices to be part of CCGs against their wishes, in a move that the GPC says makes a mockery of Government claims of GP support.

A misnomer

Dr Chaand Nagpaul, GPC negotiator, says: ‘The idea that CCGs are membership organisations has always been a misnomer because all membership organisations give you a choice over whether to be a member or not.

‘These are forced membership organisations and the Government has made it clear that those GPs who don’t agree to be in the CCG will be forced to be in the CCG.’

This of course applies when the reforms are up and running: practices that disagree with their CCG will not be able to cancel their membership.

As part of the authorisation process, CCGs were meant to be assessed on their engagement with practices, and at first glance, appear to have done rather well.

The NHS Commissioning Board gave 204 of the 211 CCGs across England a perfect record for their engagement with GP practices, on criteria such as whether the constitution has been signed off by member practices, whether GPs have been involved in ‘decision-making processes’ and whether there were safeguards for managing potential conflicts of interest.

Of the seven CCGs given black marks on GP engagement, only three have been given ‘conditions’ that go beyond being given advice by the board on improving engagement.

When I look at some of the pronouncements coming from certain CCG leaders across the country it makes me shudder

Dr Robert Morley

But LMC leaders say this rosy picture does not reflect what they are hearing on the ground. Dr Robert Morley, secretary of Birmingham LMC, says: ‘Of course CCGs have “engaged” with their practices, as every practice has to be a CCG member, and some CCGs I’m sure have done a good job of this. But others have done far less well.’

He adds: ‘When I look at some of the pronouncements coming from certain CCG leaders across the country, and some of the unacceptable obligations they are trying to put on practices, particularly in their constitutions, which we now know are to be legally binding documents, it makes me shudder.’

Dr Andrew Mimnagh, chair of Sefton LMC, says CCGs have met targets, but this does not mean their practices are fully engaged.

He says: ‘It depends on what level you define engagement. It is fair to say that until now everyone has been turning up to find out what is happening, but that is not quite the same as saying there is a universal, permeating shared value.

‘Do I think they have reached the targets they have set? Yes, I would be reasonably assured. But that is not saying they got 100% GP engagement.’

GPs are also seeing increasing levels of performance management by CCGs, with 83% seeing some sort of pressure from CCGs, and 16% saying they have had a lot of pressure to improve their performance.

‘Command and control’

There are even signs that commissioning enthusiasts in some areas are beginning to lose heart.

The much-reported case of Lewisham CCG – whose opposition to the downgrading of Lewisham Hospital A&E went unheeded by the health secretary – has highlighted concerns that CCG leaders will not have the freedom they need to shape local services.

Controversial competition rules – despite a much-publicised rewrite by the Government – are still likely to compel CCGs to use any qualified provider unless they can demonstrate that only one ‘single provider’ can provide a service.

GP commissioners will also have to work with local authorities to sign off their public health plans and cope with an unprecedented financial squeeze.

When Pulse conducted off-the-record interviews with 43 GP chairs of CCGs last month, one in three said they thought they had less power and influence than they expected to have when they first took up the role. And some have gone further, accusing the NHS Commissioning Board of taking a ‘command and control’ approach to the new organisations.

Command and control is the way that many people in the NHS Commissioning Board still think

Dr Tim Moorhead

Speaking at a commissioning event last week, Dr Tim Moorhead, chair of NHS Sheffield CCG and a GP in the city, says GPs are at risk of becoming ‘slaves to regulations and rules’ set nationally.

He says: ‘I have a broad perception that the relationship of command and control is the way that many people in the NHS Commissioning Board still think.

‘The culture of fear that went with that, of which so much has been said recently, is part of it and is very unhelpful. We need to get away from that enforcement dictated by the centre.’

‘I sometimes think the NHS Commissioning Board needs a bit of help to let it know it will be OK if it just lets go a little bit, gives us the tools to do the job and allows us a little bit of independence. Yes, we ought to be accountable, but I don’t want to be interfered with.’

Others agree. Also at the event, Dr Junaid Bajwais, board member of NHS Greenwich CCG and RCGP clinical commissioning champion, says the authorisation process was an example of board ‘micro-management’. He says: ‘The risks are stacked against us, plus there is the Nicholson challenge. So they have no option in their minds but to go to this default position of command and control.

‘As for micromanagement of CCGs – 119 competencies to go through authorisation and you have to score greens and reds? I think that is complete micromanagement.’

Dr James Kingsland, national clinical lead of the NHS Clinical Commissioning Community and a GP in Wallasey, Merseyside, confirms he is hearing ‘mixed reports’ from CCGs.

‘Some CCGs are saying clinical leadership is flourishing, practices are engaged, they are facing their public.

‘Others are saying it feels very much like the relationship between the SHA and the PCT, where we are facing a reporting system to demonstrate we have done certain things that are required by the area team, which is concerning as we are supposed to be having a completely new system.’

Many CCG leaders face strict curbs on their freedom from the NHS Commissioning Board, with 15 facing ‘legal directions’, which in most cases impose an individual upon the CCG but, in more extreme cases, could remove the accountable officer or even certain functions.

Financial challenge

Dr Simon Hambling, who was leader of NHS Cambridgeshire and Peterborough CCG until August 2012 when he was voted out over proposals to hire more managers, says CCG leaders are beginning to wake up to the extent of the financial challenge they will have to face.

He says: ‘The ability to make significant changes has been very much hampered by the financial settlements that have been given to CCGs.

‘There is a lack of resources for the organisations that will make it very difficult for them. The settlements that have been handed down are extremely tight. Without money to invest, CCGs are going to struggle.’

In some areas, historic deficits will mean CCGs are going to start at a significant disadvantage, most notably, the CCGs in the NHS North Yorkshire & York area, which, according to the NHS Commissioning Board, is the only PCT to be passing on a debt.

Dr Mark Hayes, chief clinical officer at NHS Vale of York CCG, says it will have a senior finance director imposed on it by the board, but insists the process so far has been positive.

‘You look at the NHS management and you think it is all command and control, but interestingly our experience is that this process is different – it doesn’t feel like the SHA marking your homework, it feels as if they are helping us be the best CCG we can be.’

He adds: ‘What the [financial situation] does mean is that we have for a number of years been focused on this problem and perhaps, if you look for the silver lining, we might be in a better position than some other areas where they haven’t had this problem. In the next year there are going to be a lot of financial problems up and down the country for providers and commissioners. Maybe we have a slight advantage.’

So three years after Mr Lansley pledged to put NHS ‘ownership and decision-making in the hands of professionals and patients’, how close is his dream to becoming a reality?

As far as GPs are concerned, it seems there is still a long way to go.