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At what point does GP-led commissioning stop being GP-led?

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The investigation last week by Pulse’s senior reporter Jaimie Kaffash into the number of GPs stepping down from CCG boards rightly attracted plenty of attention – including a rare piece of joint national coverage with GP magazine, who conducted a similar investigation, in the Daily Mirror.

While some degree of turnover is of course to be expected, it is certainly striking that so many enthusiasts involved with commissioning at a senior level, including at least four CCG chairs, have stepped down within the first six months of assuming commissioning responsibility.

But the investigation also threw up another startling statistic.

Out of 949 board positions across 74 CCGs, just 406 were filled by GPs. That’s only 43% (and while our sample looked at only a third of CCGs, GP magazine’s investigation, conducted entirely separately, came up with the same figure).  

A relatively small proportion then, and a falling one. A similar Pulse investigation in July 2012, across 100 CCGs, found that GPs filled 49% of CCG board seats. The exact proportion may be out by a percentage point or too, but the trend is clear: GPs are now very much in a minority on CCG boards, and their voice is getting quieter.

Even outside the profession, those figures have caused some consternation. The health commentator Roy Lilley said: ‘Astounding, as these reforms are all about docs being in the driving seat. We are well on our way back to PCTs.’ Dr Gabriel Scally put it even more pithily: ‘Whatever happened to giving control to GPs?’

The decline in GP representation is perhaps the inevitable consequence of the watering down of Andrew Lansley’s vision over the past three years. Initially we had GP consortia, with general practice firmly in the driving seat. Then we had the NHS Future Forum’s fudge of clinical commissioning groups, with consultants, nurses and even lay people given much more of a voice. Now enthusiasm even among commissioning pioneers appears to be dwindling.

The temptation for many GPs, particularly those sceptical of the reforms in general, may be to shrug their shoulders. Many grassroots GPs stopped regarding CCGs as GP representative bodies a long time ago. But general practice’s declining power on CCG boards should matter to every GP in England, and for two reasons.

Firstly, whether or not you support the concept of clinical commissioning, for it to be a success, for it to actually make a difference, it must fully involve general practice. Only if a sufficient number of GPs – preferably the coalface doctors who wouldn’t normally get involved in this kind of thing – take part in decision-making will clinical commissioning actually help improve the fortunes of the NHS. Given the NHS reforms have already cost the health service hundreds of millions of pounds, simply recreating what went before should not – cannot – be an option.

And secondly, regardless of who actually makes decisions on behalf of CCGs, it is GPs who will be held responsible and who will have to defend them. If the general public can tell you one thing about the NHS reforms, it is that GPs are now holding the purse strings. Never mind who sits on the board; CCGs are membership organisations constituted of GP practices, and GP practices alone. Chances are, over the next few years your CCG is going to have to make some pretty difficult calls – on rationing, on restructuring – and you and your practice will be held accountable for them.

Like it or not, in the public’s mind GPs now run the NHS. For as long as that continues to be the case, it’s essential that practices have a direct say in the decisions which actually matter.

Steve Nowottny is the editor of Pulse. You can follow him on Twitter @stevenowottny.

Readers' comments (8)

  • Telling GPs they are members does not make us feel like members, and certainly it does not feel as if we have control of anything. When the job is to attempt to save cash while giving patients exactly what they ask for, it is clearly impossible. The larger the organisation, the less likely an individual voice makes a difference- giving good advice to a board takes a lot of work and GPs have too much even before the changes- When those who enjoy management (and ran the PCTs) start pulling out, the government should think about whether this is a way to run the NHS. With the constraints on CCGs, the old (smaller) PCTs with their clinical executives had more GP influence, whatever the politicians say. The press need to make the people realise that there is no GP led NHS- leading the NHS is a very energy and time consuming job when done properly, and doctors do not like to do things badly. We are short of GPs, so replacing time out for management is not possible. I do think we have useful skills and knowledge to manage change, but if the most experienced GPs give up (even part of ) the day job, patients in primary care will miss out.

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  • I agree with your statement: "Only if a sufficient number of GPs – preferably the coalface doctors who wouldn’t normally get involved in this kind of thing – take part in decision-making will clinical commissioning actually help improve the fortunes of the NHS" however as an ex-CCG Board Member I can honestly say that this is pretty impossible to achieve. I remained a coal-face jobbing GP working 6 sessions a week as well as doing 3 sessions a week as a Board member, I had never done any clinical commissioning work or any management of any kind prior to my board position and was only enticed to join due to my interest in Public Health, Education and in working on integrated pathways of care with social services. As the work and responsibilities increased a good proportion of my fellow board members became practically full-time and decided to give up their partnerships. I feel this is the wrong thing to do because inevitably management becomes a career and their independent voice as a jobbing GP is lost. My voice became increasingly isolated and I lost faith in the whole concept of a GP led CCG. If GPs spend more time in the CCG and become dependant on management for their careers and job prospects, then they will inevitably start to think like managers and the CCG becomes yet another PCT.

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  • Commissioning was never intended to be a tool for the benefit of the NHS and its employees & patients. Call me a cynic but I see it simply as an (expensive) exercise/con by HMG. Its real purpose is to yet again demoralise and dumb down the profession, allowing HMG to say, "nope not our fault, all the fault of GPs as they hold the budgets". This will lead to further demonisation by Murdoch's attack dogs. The public will distrust GPs even more (if that's possible) and HMG will sense that the time is right to go for the jugular/carotid and privatise the NHS. So sad.

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  • Well said Anthony Matheson.Alot of these GPs are idealistic morons

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  • Nobody, however well-motivated can go out shopping with an empty purse. GP Commissioners= GP scapegoats.

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  • @above who wrote "GP Commissioners= GP scapegoats"

    And you couldn't see this coming?If some of you are that naive then you deserve everything you get.It makes one wonder what type of simpletons are in these positions.

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  • GPs as a group have a strong voice and could have resisted all these useless changes within the NHS by simply refusing to 'play the game' with HMG. They have earned more money than ever before over the last 10 years and yet keep bleating on about increased work loads and stress. Answer = Refuse to do additional work, earn a bit less money, have less stress and more time to devote to patient care and CCG. Or, retire early...

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  • Unity is strength. CCGs can
    refuse unreasonable demands.

    Stand up and be counted now and you have HMG by the short and curlies.

    Whine as per usual and HMG will have your profession as the permanent fall guys for delivering bad news.

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