It has been the elephant in the room for some time, and it is getting bigger – the question of whether CCGs should be responsible for commissioning primary as well as secondary care.
An inherent contradiction in the 2012 Health and Social Care Act means that CCGs have a responsibility for quality in primary care yet have no say over GP contracts, which are held by NHS England. The reason behind this is to avoid potential conflicts of interests. But it is a stipulation that has, not surprisingly, caused confusion about CCGs’ roles in relation to primary care.
The issue has been further complicated by the move towards integrated care. CCG leaders have been questioning how they go about moving services out of hospital if they cannot actually commission services from primary care and have no say over such matters as GP practices’ performance or the scale at which they operate.
That – coupled with growing dissatisfaction among both CCGs and practices about the performance of NHS England and its local area teams – has brought matters to a head. Area teams are seen as having too big a remit and NHS England is visibly struggling with locality issues and the performance management of primary care. This has led to reports of ‘power struggles’ between CCGs and area teams as GP commissioners take matters into their own hands.
A ‘hiatus’ in primary care
Commissioning leaders are forthright in what they think should happen. Dr Michael Dixon, president of NHS Clinical Commissioners, but speaking in a personal capacity, told Pulse in August: ‘CCGs should be handed the full primary care budget because NHS England are failing to invest in GP practices.’
Dr Dixon claimed that there had been a ‘hiatus’ in the development of primary care since NHS England took it over. This, coupled with underfunding in previous years, meant GP commissioners were unable to provide the services they wanted. He admitted the idea was ‘controversial’, but said he had recently come to think that there was no alternative if the NHS was to be truly primary care-led.
Julie Wood, Dr Dixon’s colleague as interim commissioning development director at NHS Clinical Commissioners, says the organisation is now officially backing a change: ‘We feel CCGs need to play a key role in the commissioning of primary care.’
‘I think it’s inevitable that CCGs will take on more of a role in primary care. It’s part of the solution to the problem of “silo mentality” in the health service.’
Dr Nigel Watson, chair of the GPC commissioning subcommittee
She says local area teams simply haven’t got as much ‘capacity’ as PCTs had – and are unable to shape primary care in the way CCGs need. ‘It’s no good with primary care going in one direction and CCGs in another. It’s a recipe for disaster.’
And CCGs actually holding GP contracts as well as the primary care budget could be part of the solution, she says: ‘It could either be that the CCG does most of the commissioning of general practice while GP contracts sit with the NHS England – or you could go the whole hog.’
Some CCGs may relish the challenge of going ‘the whole hog’, but others are not so sure.
Dr Bill Tamkin, chair of NHS South Manchester CCG – which already has a close working relationship with its area team – is typical among CCG leaders in that he recognises that the current situation is anomalous but fears the solution. He says: ‘CCGs are responsible for quality in primary care and not the budgets but having to take on a contractual role over GPs could undermine CCGs’ ability to do high quality commissioning.’
Dr Nigel Watson, chair of the GPC’s commissioning subcommittee and a member of NHS England´s GP strategic commissioning group, believes CCGs can get the control they need over primary care without taking over GP contracts.
‘I think it´s inevitable that CCGs will take on more of a role in primary care. It’s part of the solution to the problem of “silo mentality” in the health service. With the crisis that general practice is going through in terms of workload and recruitment, CCGs could be part of the solution allowing practices to work together in bigger units.’
‘I think there´s a lot of confusion about this. The core contract needs to remain with NHS England. But if we’re going to be able to deliver services in a different way CCGs will need to be able to commission non-GMS services from practices.’
NHS England area teams will still have an important role, he adds. ‘There’s still a huge amount of things they need to do so they won’t disappear.’
NHS England taking action
While carefully avoiding pointing out the ‘elephant’, NHS England has already tacitly recognised the problem in its Improving general practice – a call to action consultation launched at the beginning of August.
In setting out the case for a re-examination of general practice, NHS England acknowledged a role for CCGs in planning primary care, and said general practice needs to be more flexible and locally responsive to CCG agendas.
The man behind the review, NHS England’s deputy medical director Dr Mike Bewick, is already clear about what needs to be done. ‘Area teams when working on primary care strategies work best in collaboration with CCGs. You´ve got to talk to people who know their business,’ he says.
‘If you were commissioning renal services you’d talk to renal specialists. If you’re commissioning primary care, GPs need to be involved. I don’t know anybody better than GPs to know about what’s needed in general practice and primary care.’
CCGs won’t be put in charge of GP contracts under his watch, he says, but he envisages much greater input from CCGs into NHS England’s decisions: ‘This is under statute and it can’t and won’t change. CCGs can’t hold GP contracts. You have to maintain the Chinese walls between the two. There has to be a clear line of governance. But CCGs could come to an area team with a description of what they need and that might be taken up 100%.’
Impetus for a greater role for CCGs could be supplied by another review currently underway and due to report this autumn.
Monitor – the NHS regulator – is also looking at primary care with a specific remit to examine the commissioning and provision of GP services and look at any potential barriers to new models of primary care being implemented. That will include the question of who commissions general practice, who holds the budget for primary care and who should hold GPs’ contracts.
Whatever Monitor says though, it’s unlikely to go far enough to satisfy Dr Dixon: ‘I feel very fiercely now that CCGs should take over primary care budgets if you’re going to get proper redesign of services. It’s simply pragmatic. Area teams are so sparse and knowledge and willingness in CCGs is so great. There’s an appetite for this among CCGs and a dissatisfaction with NHS England.
’There´s a frustration that the job of reorganisation can´t be done with money caught in different silos. It’s an organic development. It’s only pragmatic that the intelligence in primary care lies locally.’
To Dr Dixon, that also means CCGs performance-managing GP practices: ‘Legally, the contracts still need to be held by NHS England but CCGs need to be in charge of them.
’CCGs are the ones for getting rid of the rotten eggs – if they are not improvable. The peer group is best to judge whether they need help to improve or whether they’ve lost patience with them. A peer group doing it honestly and effectively has always been better than doing it remotely. The problem for 95% of GPs has been our tolerance of the bad 5%.’
Conflicts of interest
And in what is shaping up to become something of a political battlefield, any move to hand GP contracts or primary care commissioning budgets to CCGs will be opposed all the way by the BMA.
‘Area teams when working on primary care strategies work best in collaboration with CCGs. You’ve got to talk to people who know their business’
Dr Mike Bewick, NHS England deputy medical director
Dr Richard Vautrey, GPC deputy chair, told Pulse this month: ‘GPC does not support CCGs being given the budget for commissioning general practice. CCGs were not given commissioning responsibility for general practice at the time of the health bill reforms for good reason, to avoid conflicts of interest and avoid GPs in CCGs having to performance manage their own contracts.’
But for Dr Dixon, conflicts of interest are easily dealt with: ‘There’s too much made of conflict of interest. There is a conflict of interest but that can be managed within CCGs, perhaps by having a lay majority on the board.’
Interestingly, Dr Bewick believes the current structures are adequate to balance out conflicts of interest: ‘I´m not in favour of a lay majority. And there are already checks and balances in the system. Health and Wellbeing Boards will question decisions and while they may not have a statutory function to do so, they will certainly scrutinise commissioning decisions.’
Dr Watson fears a return to the bad old days of bloated PCT-type organisations if more lay members are added to CCG boards. ‘Lay people on the CCG board can play an important role but we don´t need more of them. We purposefully moved from 152 PCTs to create smaller organisations. If we have more lay non-executive directors on CCGs we´ll end up with the same board costs as before.’
But Dr Dixon believes CCGs can cope: ‘There´s always a danger of recreating PCTs but the difference is that now the clinician is leading. In CCGs it’s either the chair or the accountable officer. The accountable officer is a clinician in 40 CCGs now and that will increase. It’s the people doing the work that matters.’
In political terms, Dr Dixon believes the time is right for change. He points to the Department of Health’s plans to ‘refresh’ its Mandate to NHS England in the wake of the Mid-Staffordshire scandal and the A&E crisis as evidence that NHS England is in a weakened state and ready to relinquish some of its responsibilities.
’People are really getting behind the idea now. And there’s a shift in the centre of gravity from NHS England back to the Department of Health in terms of the Mandate. It’s a bit of a land grab. There´s a wider recognition that NHS England has bitten off more than it can chew.’