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Should CCGs performance manage GP practices? Yes


It's important for CCGs to have oversight over local practices, argues Dr Charles Alessi

In times of austerity, it's better for GPs to be transparent about the tough decisions they must make, and how they plan to improve standards of care.

In less than a year, the majority of CCGs will become autonomous. They will be held accountable via their health and wellbeing boards and the NHS Commissioning Board for their performance, judged more by the outcomes they achieve than the processes by which they achieve them.

It is unlikely the climate of austerity will change over the next few years. The decisions CCGs will face may be difficult – we are in a new world of zero-sum gain where we won't be able to invest in anything unless we disinvest in something else. Prioritising care in a more integrated and transparent way is the only way to manage.

We also need to think through what the behaviours are that will make CCGs more likely to achieve their aims. NHS managers have tried to impose repressive and authoritarian regimes in the past and, as we know, they all fade and fragment in the attendant micromanagement they create. The critical flaw has all too often been the lack of ownership over these schemes.

The unit of currency that makes up a CCG is the individual GP practice. The CCG is thus a reflection of its constituent practices.

The relationship between the CCG and its practices is going to be the key determining factor in its success. If the CCG agenda is not owned by the practices, how can clinical behaviours change at practice level? We know that for system change to be successful, the people who implement it must engage with it.

We are seeing a whole spectrum of relationships in aspiring CCGs. In some, the more extreme aspects of the old regime seem to persist – where management still tells people what to do and relies on fear and punishment to deliver. 

This tactic is unlikely to be sustainable or successful. It has become clear that the NHS Commissioning Board won't have as many outposts as originally trialled. This is a positive development, because it shows that the board is starting to take the autonomy of CCGs seriously. (Its duty to do so was highlighted prominently in a recent letter from the health secretary to the chair of the NHS Commissioning Board).

In other CCGs however, it is clear that a new way of working is being developed, born out of the appetite to manage unwarranted variations that persist in the NHS. If GPs wish to introduce systems of management via CCGs that go beyond what we have been used to in the past, and practices introduce these voluntarily, this is to be welcomed. 

With the approval of the NHS Commissioning Board, CCGs can get much more involved in the management of primary care than the PCTs and SHAs that went before. Some CCGs have realised that they must work on relationships within, and that engaging with their constituent practices gives them a greater chance of successfully prioritising resources given their tight budgets. The key to success is consensus. If some CCGs are taking on responsibilities of management of primary care, it is important they do so with the support and buy-in from their constituent practices. The behaviours the new CCG leaders need to exhibit are very different to the linear style of old. New GP leaders need to start to develop their own autonomous behaviours, and make their presence felt as the NHS changes.

All transitions can be messy, and the next six months are probably where it is likely we will have a few problems, especially where some of the existing PCT clusters and new CCG structures continue to exhibit the old behaviours. We need to remain focused on engagement – a difficult task when the emphasis is so firmly now on authorisation.

But if we remain focused, there is a far greater chance of delivering better health and social care within the resources we have available.

Dr Charles Alessiis chair of the National Association of Primary Care and a GP in Kingston upon Thames