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GPs must approve constitutions

Despite all the drawbacks inherent in the Government’s NHS reforms programme, the idea that clinicians should be deciding how care is organised locally is almost unanimously supported.

Yet, ironically, this is the aspect being put at risk by the way CCG constitutions are being implemented by the NHS Commissioning Board.

In September the GPC warned that the warm, fuzzy notion of clinical commissioning was steadily being undermined in some areas by the cold, hard legal terms of CCG constitutions.

Punitive performance management, gagging clauses, powers to expel practices, lack of recognition of LMCs; all these, and more, are being added to constitutions to enable CCGs to exert their influence over primary care.

The GPC advice was simple – if the constitution contains something you do not like, or misses out something vital, then refuse to sign it. But, as we reveal this week, leaving the dotted line blank provides absolutely no protection.

The board has made the startling admission that a CCG can be authorised without a single practice signing up to the constitution. As long as the CCG can demonstrate in other ways that it has the support of GP practices, no signatures are needed.

In response to queries from Pulse, a spokesperson from the board even had the audacity to say she did not understand our ‘fixation’ with signatures. ‘There could be CCG constitutions without any signatures’ she said, baldly.

Even worse, because GPs are contractually obliged to join a CCG from April, the GPC admits that, if a GP refuses to sign the local CCG’s constitution, he or she could still be subject to it when allocated a CCG in April 2013.

The net result of this is that GPs will be under the cosh of these agreements whether or not they sign them. Machiavelli could not have planned it better.


If this happens, there is a real risk that GPs will become completely alienated from the whole CCG project before it even starts.

There were already questions around the way CCGs were engaging local GPs in decision-making, and the legitimacy of CCGs rests on their being supported by the practices that make them up – otherwise they risk merely becoming smaller versions of PCTs.

The formation of a CCG should be a coming together of practices, not a forced marriage brokered by a punitive legal agreement. The NHS Commissioning Board must take this seriously and ensure that the vast majority of practices are signed up to these legal agreements – or ask why not.

The GPC also urgently needs to advise practices what they should do when faced with an agreement they do not support. If the rumoured 50% threshold for signatures in order to qualify for authorisation is true, then LMCs should be encouraged to coordinate the response to a constitution from practices.

With the first CCGs to be authorised in less than a month, there is precious little time to waste.