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Big brother – or a light touch?

The exact role of CCGs in performance managing primary care is still being worked out. But however big or small the eventual role, a line will have been crossed in that for the first time, clinical leaders will have an obligation to scrutinise their peers.

Some anticipate this will mean CCGs adopting a Big Brother-type role, while others question whether GPs will really highlight those practices that are on dodgy ground when it comes to quality .

A recent survey by Londonwide LMCs showed that despite having been performance managed by PCTs for 10 years, nearly 80% of GPs remained worried about being performance managed by their CCGs.

Dr Michelle Drage, London LMCs chief executive, recently told Pulse the prospect of CCGs ‘doing performance management’ of their members, as well as ‘doing commissioning’, risked turning the culture of CCGs into that of PCTs – the very bodies the health act was designed to abolish.


The case for change

It is an accepted fact that standards in general practice vary across the country. Professor Steve Field, chair of the NHS Future Forum and former RCGP chair, told last year’s NHS Alliance conference the NHS had ‘lost the plot’ on primary care provision, citing too much variation and unacceptable access in some parts of the country.

And at last month’s conference of independent think tank Reform, NAPC chair Dr Charles Alessi said CCGs needed to ‘look inwards’ to reduce unwarranted variation in the care and access provided by its practices.

There are signs that some CCGs are already taking matters into their own hands.

Our sister paper Pulse reported last month that CCG leaders in London had lobbied the NHS, demanding a toughened-up system for managing the performance of practices.

A board paper from NHS Central London revealed Islington CCG had asked NHS London to make its GP Outcome Standards process ‘less light touch’.


Conflict of interest

Alan Gavurin, founder and managing director of Damson Health primary health consultancy, thinks CCGs will have to take on some of the responsibility for performance managing primary care, simply because other bodies are too remote and don’t have the capacity to do it themselves. A process of elimination means the buck may have to stop with CCGs.

‘A lot of people are quite anxious about how this is going to work. If you look at who is available, I worry that if the NHS Commissioning Board or its outposts do it, it is going to be a bit of an afterthought and all the skills PCTs have built up over the years in managing GPs will be lost and they’ll need to develop a new set,’ he said.

‘The Commissioning Support Services will be really focused on big-scale commissioning and won’t have the local sensitivity needed to manage GPs. So that leaves CCGs – and there has to be a conflict of interest involved in GPs managing themselves.

‘And will GPs really turn the harsh glare on one another? I don’t think they will.’


Means to an end

So what methods could, or should, CCGs use to performance manage members?

Dr Nigel Watson, BMA commissioning subcommittee chair and a member of the Department of Health’s commissioning strategy group, told Practical Commissioning that the issue had now been thrashed out in talks between the BMA and the DH.

‘There will be peer review within CCGs and there may even be some peer pressure, but you do not want to have a system where the same people people are being judge, jury and executioner,’ Dr Watson said.

‘The Local Area Team of the NHS Commissioning Board, or LAT, will be responsible for performance management, and I expect the process used by the LATs for practices to be similar to that used for individuals. LMCs should be involved in that. CCGs should be involved in providing information – but not in judging GPs.’

But Elizabeth Wade, head of commissioning policy and membership at the NHS Confederation, told Practical Commissioning she believes there is still scope – and good operational reasons – for CCGs to take a bigger role.

‘The responsibility for GP contracts will be with the NHS Commissioning Board – but the legislation includes provision for the board to delegate this, or some aspects of it, to CCGs,’ she said. ‘There are mixed views on whether that will be a good thing or not. On the one hand, CCGs could have conflicts of interest and also potential problems around their relationships with practices. It could be harder to get practices on board with commissioning if the CCG is having to performance manage them.

‘The advantage though, is if you want CCGs to look at the totality of care locally. In some ways it makes sense having them involved in managing primary care if they are moving resources from secondary to primary care and managing community services.’

Ms Wade also warns local capacity issues could be a factor, with some advanced CCGs taking on this new role while others, still getting to grips with core commissioning, might not be ready to do so. The default then would be for commissioning support services to take it on or to develop a framework with other CCGs.

Dr Paul Charlson, chair of Conservative Health, believes that whatever the nominal responsibilities, some element of performance management of GP practices by CCGs is inevitable.

He predicts the board’s forthcoming operating model will give CCGs a combination of carrots and sticks to use.

He says: ‘CCGs will need a robust framework for this. The quality premium is a tool to encourage practices to play ball, really. CCGs can’t deploy sanctions because they do not hold the contract.

‘But the bottom line is, if someone is seriously underperforming, the CCG will say to the board, “we are not very happy, we have got concerns” and the board may initiate discussions about their contract.’