The connection between practices and commissioning is the ‘unique selling point’ of CCGs according to Dr Johnny Marshall, interim partnership development director for NHS Clinical Commissioners.
‘Membership organisations made up of GP practices makes a real connection between practices and commissioning – perhaps the thing that PCTs struggled most with. This is the unique selling point of clinical commissioning groups.’
The vision of a grassroots commissioning revolution set out in the 2010 White Paper, with like-minded GP practices coalescing into CCGs as if by magic hasn´t quite come to pass. There has inevitably been an element of PCTs handing over the control levers to another set of managers. And inevitably many practices are still not convinced about the reforms, let alone ready to take on a meaningful role in commissioning.
So how, with two months to go before CCGs finally come out of the shadows, are CCGs going about the crucial task of ensuring sign-up from practices and winning hearts and minds?
1/ Get practices to get the discussions going
CCGs are already learning that in order for practices to engage with them, they have first to engage with each other.
For Dr Marshall this is the central issue of engagement: ‘You have, as a community, to understand what the local challenges are and that means you need to establish a high level of shared purpose between practices and make sure that contributes to planning care for patients.
‘It´s a trust issue – and it’s important for practices to hear each other´s points of view. It´s also about practices beginning to take responsibility – not just for the patient in the consultation- but for their whole local population. That in turn involves being proactive about patient care and not just reactive.
‘The most important thing about this is to realise that it takes time. And it´s imperative we look at the time spent on this as a potentially worthwhile investment.’
NHS Greater Preston CCG is using practice peer groups to give individual member practices an understanding of wider priorities across the CCG.
CCG chair Dr Ann Bowman says it has been an uphill struggle: ‘We´ve gone from open scepticism and even outright hostility among practices to some degree of acceptance and now, in some cases, even interest!
‘We´ve achieved this by starting with the model of peer groups – getting practices with different profiles together so they can appreciate each other’s priorities and difficulties. Around half of our practices are singlehanded and we´ve deliberately mixed these up with other practices so they can get the bigger picture. We also have some very rural and some city-based practices and again we´ve mixed these up so they can learn about each other.
‘Meetings take place in lunchtimes and are attended by at least one GP from each practice as well as practice managers and nurses. Single-handed practices in particular tend to rely heavily on practice nurses as the GPs tend to be focused on the clinical side of things. It´s useful for practices to learn how others handle emergency call-outs for example. There are dozens of different ways of doing this and it helps to help spread best practice.”
Dr Marshall believes the process of preparing the Joint Strategic Needs Assessment is a ready-made vehicle for improving practice engagement. ‘With the JSNA, you start presenting information to practices about their surrounding areas that they might not have seen before. Part of the process is trying to understand what role each practice can play. And local needs assessments can be different from the overall one.
‘Engagement starts by looking at and trying to understand everyone´s perspective and recognising that these are going to vary from practice to practice.’
2/ Divide and rule (and unite)
The bigger the CCG, the more difficult effective practice engagement can be. For Dr Matthew Davies, GP locality chair at NHS Nene CCG – a 600,000+ patient CCG with 72 practices – the key is splitting commissioning issues into those which are CCG-wide and those that are specific to localities. Nene CCG now has eight localities of between six and 14 practices. All member practices are allocated protected learning time at CCG, locality and practice levels – funded out of CCG running costs.
‘That way we show our commitment to practices which is an important part of the deal.’
NHS Nene CCG first formed as a practice based commissioning company in 2007 and twice won the Vision Awards Most Advanced PBC Consortium in the UK award before becoming a pathfinder CCG in 2010. That has enabled long-term work on practice engagement to pay off.
Dr Davies says the CCG is seeing better and better engagement among practices. ‘It takes time but we have actually moved on from the idea of engagement to focusing on actual involvement in commissioning. For us as a CCG to be a success, all our practices have to be a success.’
As a background process, Dr Davies believes that the financial pressures the NHS is under is also forcing practices to ‘understand and engage’. ‘You realise the NHS can´t carry on as it is. You can´t ignore that you have to talk to other people involved locally and find new ways of caring for patients.’
3/ Communicate in multiple ways
CCGs have many means of communication at their disposal and should use all of them, according to Dr Marshall.
‘It´s inevitable there are going to be lots of meetings involved in running a CCG – but engagement is helped by being clear what each meeting is for. Form needs to follow function. You must meet for a purpose as practices are so busy.’ But he believes practice engagement can be made much more streamlined – and democratic – by being careful about meetings and employing technology where possible.
He points to the fact that more and more CCGs are using IT – including social media – to solicit and maintain practice engagement: ‘Video conferencing and even phone calls are helping with geographically spread-out populations, especially as getting to meetings in rural areas can be a trek.
‘Some CCGs are using Twitter as a means of keeping in touch not just with practice but with practice populations, too. People are trying all sorts of different things, from email newsletters to video clips on YouTube.’
In Preston, Dr Bowman´s CCG uses SharePoint – a website specifically for the CCG – where all relevant documents are placed for ease of access – the minutes of every meeting, a monthly newsletter as well as links to the burgeoning number of national documents produced by the NHS Commissioning Board and Department of Health.
4/ Have a named commissioning lead in every practice
Many CCGs have named commissioning leads in each practice who acts as glue and conduit between the CCG and the practice.
NHS Wandsworth CCG for example see embedding commissioning expertise within each practice as the most effective way of developing and delivering effective commissioning skills across the borough.
The CCG developed a GP practice commissioning engagement scheme – initially run as a five month pilot scheme – to help practices develop internal systems and processes, engage clinicians in commissioning and delivery improvements in care.
Practices signing up to the scheme identify a named practice lead, a clinician who acts as the interface between the practice, the locality and the CCG.
Funding for the scheme has been provided by the CCG utilising the £2 per head organisational development budget and pays for two sessions a month to develop commissioning systems and processes within each practice.
As part of the scheme, each GP practice is expected to agree three areas of service improvement linked to local needs with the locality GP clinical lead to prioritise.
5. Appoint a GP engagement lead
NHS Dudley CCG are among those that have a GP engagement lead – a retired local GP who knows the area well – as a co-opted CCG board member. This GP’s role is to ensure that practice performance is measured in context of the practice situation and that appropriate support can be offered to that practice where required. This role is supported by commissioners and a bi-weekly publication (CCG News) ensures effective communication to practices on any new commissioning policies.
6. Involve the whole practice
Having a ‘named lead’ in a practice can of course mean that the other GPs and staff feel let off the hook and can result in patchy engagement at best. An alternative approach is to try to get the whole practice involved in the CCG.
Dame Barbara Hakin, national director of commissioning development at the NHS Commissioning Board is an advocate of the ‘holistic’ approach, in that she believes all practice staff – not just a named representative – should have a stake in the CCG.
Dame Barbara told the NHS Alliance annual conference in November: ‘Practices are key – and I don’t just mean GPs but all those who work in the practices need to own and belong and feel that the CCG is theirs. If the practice ever says “that CCG over there” you’ve lost it, you might as well go back to being a PCT.”
She added: ‘It’s absolutely key that the practice nurses, attached community staff and practice managers are intimately involved in the business of the CCG.
‘When I was chief executive of a PCT, we had a practice managers meeting where all the practice managers attended and as the chief executive of the PCT I always went to that meeting and I hope those practice managers at that time felt they were able to phone me and say ”Barbara we’re worried about this or we think this is not happening”.
‘So CCG leaders think about practices as a whole entity and never underestimate the power of practice managers in helping you to help practices be the best they can be.’
7/ Engage outside support
Some CCGs are turning to outside agencies to help get practices on board. The BMA advocates involvement of LMCs to prevent what GPC deputy chair Dr Richard Vautrey has termed a return of ‘us-and-them’ feeling among GP practices prevalent under PCTs. Dr Vautrey believes there is a danger in GPs seeing CCGs as ‘the CCG’ rather than ‘my CCG’.
Part of the responsibility for engagement lies with individual GPs, the BMA has said: “While CCGs have a responsibility to communicate with their constituent practices and local profession, all GPs, including sessional and locum GPs, should make efforts to keep up to date with developments and decisions made by their CCG in order to successfully hold them to account. It is vital that robust communications are established with all GPs in the CCG area.
It wants LMCs to pull GPs into line where necessary and ensure they engage with CCGs: ‘Local Medical Committees are the only statutory body that represent GPs and should play a pivotal role in supporting and upholding these processes. LMCs need to ensure their practices are fully engaged and that the CCG is supporting fully inclusive democratic processes. LMCs should ensure that all GPs in the area are kept informed of developments and understand the importance of engagement with their CCGs.’
8/ Incentivise engagement
Many CCGs have used local enhanced services or local incentive schemes to fund protected time for practice members – including practice managers and nurses – to engage with the CCG.
NHS Greater Preston CCG is among them, but fears that the progress they have made so far could be jeopardised by lack of funding in the future.
‘Our system of a half-day protected time per month for practices began under the PCT,’ says Dr Bowman. ‘We had a local incentive scheme with funding to pay the out-of-hours service for enough cover to enable practices to close.
‘It has developed into a two-way process now with practices´ views feeding into the CCG´s priorities and the CCG executive providing a programme of education every month around specific issues such as end-of-life care or pain management. It has worked very well but we´re now worried that funding for initiatives such as this might have to come out of our running costs.
‘It´s not clear what will happen to PCT-funded initiatives such as LISs and LESs going forward.”
‘Hopefully more practices will want to feel part of the CCG as it develops and they can see the benefits. But at the moment, most are sitting on the fence and waiting to see what we´ll do. Without funding we could really struggle for engagement.’
9/ Tap into patient power
Dr Jagan John, clinical director of NHS Barking and Dagenham CCG believes patient power will be more important in the new-look commissioning landscape than we think. ‘Personally I think patient experience will be a test for everything. The way patients interact with the CCG will change the way practices interact with it.
CCG patient forums will be key: ‘In our CCG patients from every practice come to our patient forum. When patients are involved in the CCG, they go back to their practice and they say they want certain things done in line with other practices. If the practice is not engaged with the CCG and the patients are, it´s only a matter of time before they come into line.’
10/ Revalidation is your ally
Dr John also believes that revalidation education events can be used to aid practice engagement. ‘Revalidation sits side by side with the CCG agenda. The two will work together. The things you´ll need for revalidation, the diaries or catalogues you compile will be things that the CCG has requested anyway: pathway changes for example. Training on safeguarding for example is a core requirement for CCGs – and part of revalidation. If GPs are on board with revalidation they will be on board with the CCG agenda too.’
Alisdair Stirling is a freelance journalist