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Investigation: How CCGs are beginning to reshape primary care

After many years of dwindling investment in general practice, there are the first signs of a possible shift.

A Pulse investigation reveals that CCGs spent the run-up to April quietly reworking the wiring of the NHS, in particular looking at how they can use their funding to get the best from primary care.

Figures show that CCGs have commissioned significant additional investment into local enhanced service agreements (LESs) for this year, the equivalent of £1.6m across England, in a shift that has been welcomed as evidence of more ‘intelligent’ commissioning by CCGs.

The GPC says it hopes the figures are the early signs of a wider shift that will address the anomaly of the shrinking proportion of overall NHS funding that primary care receives – currently around 8% – and help to address the need for more care to be carried out outside hospitals.

But there are clouds on the horizon. NHS England has told CCGs they need to start reviewing all enhanced services, including those commissioned from April 2013, under competition regulations that will leave them open to legal challenge if they do not use any qualified provider or a full tendering process – a change described as a ‘ticking time bomb’ by some GPs.

The deteriorating financial situation in some areas is also causing concern over whether current levels of primary care funding can be sustained.

Increased investment

Official NHS England advice from last year is that all LES agreements should have been carried over from 2012/13 unless there was ‘compelling evidence for adopting a new approach’ – and then subsequently reviewed.

But, of the 81 CCGs that answered our Freedom of Information request, a fifth (18%) had gone against this advice and have cut, redrawn or introduced new LESs from April.

Many had cancelled LES agreements with practices, or renegotiated their value, with spending cuts totalling £668,000 across the 81 CCGs.

But this was more than made up for by the new LES agreements introduced so far this financial year, and increased investment in existing LESs, with overall budgets increasing by £1.3m. This equates to a net increase in investment in primary care of £626,000 by the 81 CCGs – extrapolated across all 211 CCGs in England, a hike in funding of £1.63m from April.

Elderly care is a particular focus, with a number of CCGs starting LESs for care home or nursing home visits, including North Staffordshire CCG, where it is worth £333,000 to practices. A new LES for surveillance of PSA levels and prostate cancer follow-up is worth £204,000 in Coastal West Sussex.

This is not rocket science, you anticipate these crises and reduce their occurrence

Dr David Farmer

A number of CCGs are increasing investment in existing LESs, including Hounslow CCG, which has increased the value of its existing LES agreements by £266,000, and Cumbria CCG, which has increased the value of two LESs by £200,000.

One of those prioritising investment in primary care is South Worcestershire CCG, which invested an additional £45,000 in a new LES for sigmoidoscopy, replacing a less lucrative menorrhagia LES.

Dr David Farmer, a clinical lead at South Worcestershire CCG and a GP in Evesham, says the additional investment is because the CCG believes ‘very strongly’ in primary care.

He says: ‘Primary care certainly provides better prevention for illness and serves for a more equitable distribution of health.’

Dr Farmer gives the example of his CCG’s care home LES. In the past, he says, it was sporadic whether a GP would visit a care home or not. This would often lead to crises where either an ambulance would be called or the GP had to make an urgent visit.

He says: ‘If you have GPs going into the care home and doing regular rounds, and this is not rocket science, you anticipate these crises and reduce their occurrence.’

A raft of new LESs

Central London CCG tells Pulse it will be commissioning a raft of new LESs this year for weekend opening, nurse outreach for the homeless and palliative care.

Dr Neville Purssell, joint vice-chair of the CCG, says it has not decided how much the additional investment will be, but that it is convinced investing in GP services is the best way to address local needs.

He says: ‘Using some extra funding that became available, Central London CCG ran some small pilots last winter providing extended weekend opening hours and extra support for our homeless. The CCG took the decision that they wanted these to continue and decided to invest in them.’

This is ‘all about making best use of resources and investing in services that will address our residents’ needs’, Dr Purssell adds.

Wessex LMC chair Dr Nigel Watson says such examples are the first signs of CCGs taking a more enlightened approach to commissioning – the whole point of the Government’s reforms.

He says: ‘If you cut money from general practice, all you will get is more people going to hospital. That will be more expensive and make no sense.

‘We’re beginning to see some reasonably intelligent commissioning where they are doing the work while complying with legislation, so we just have to wait and see how that develops. Most CCGs are only just getting up to being fully staffed so I think we’ll have to wait.’

LES funding had been dropping in previous years. Official figures from the NHS Information Centre in September last year revealed that GP practices suffered a large drop in LES funding in 2011/12 that was not recovered in 2012/13. Funding for LESs fell from a peak of £336m in 2009/10 to £269.6m in 2011/12. This backed up findings from a Pulse investigation last year that showed cuts in LES funding of nearly 50% in some areas.

The latest DH accounts show that the proportion of NHS funding allocated to GPs has dropped overall to 8.6%. This compares with 8.8% in 2010/11 and 9% in 2009/10.

GPC deputy chair Dr Richard Vautrey says redressing the balance between funding of primary and secondary care has to be a priority for CCGs in order to shift more care into the community.

He says: ‘The proportion of funding has dropped and we need to drastically increase that if practices are to be able to do all the work they are expected to.’

He adds. ‘We would want to see CCGs investing more in general practice and the community and the LES contract is their way to do it.’

Warning signs

But GP leaders issued dire warnings last year about the impact of competition legislation on LESs – with one LMC leader warning of heavy financial losses and the prospect of redundancies. So has that threat receded?

Many of the LES funding changes reported to us by CCGs were agreed before April, but from the beginning of the new financial year, the controversial Section 75 competition regulations apply. As part of the regulations, any services commissioned from now – including LESs – will need to go through AQP or a full tendering process unless the CCG can prove there is only one possible provider. 

As Dr Farmer puts it: ‘Whether LES reviews will result in increased or decreased spend on LESs is not always within the gift of CCGs, but we are keen to grow primary care.’

CCGs will need to review LESs this year, with NHS England compelling them to commission them as new ‘local services’ from 2014/15.

Dr James Kingsland, national clinical lead for the NHS Clinical Commissioning Community and a GP in Wallasey, Merseyside, warns that the competition rules are a ‘ticking bomb’ and that GPs are ‘not particularly well geared to go into a competitive market and we have got the independent and commercial sector coming in, much better skilled at bidding in competitive tendering procurement’.

The ticking time bomb is that GPs will not be the preferred provider

Dr James Kingsland

Click here to read his full comments

CCGs will have a degree of discretion as to whether to tender services or use AQP. They will need to focus on how the existing funding is deployed in their current member practices but – as Dr Kingsland says – ‘they have to do it so that it doesn’t look as though it is a monopoly arrangement’.

In other words, GPs may well be able to continue with current GP services if the CCG can prove this is the best process for maintaining and improving patient care. But there will be times when practices may have to compete to retain services they provide under LESs.

In the case of public health LESs, which are now commissioned by local authorities, the situation is even more worrying. The DH has urged local authorities to put most public health LESs out to tender, and a Pulse Freedom of Information request earlier this year revealed North Yorkshire County Council has put LESs worth £1.8m out to tender already.

Financial squeeze

There is also the problem of the financial squeeze on CCGs. For example, just three months into assuming responsibility, Oxfordshire CCG revealed last month that it had allocated all but £3.3m of its £658m budget – 0.5% – for this financial year, with nine months still remaining.

Dr Paul Roblin, chief executive of Berkshire, Buckinghamshire and Oxon LMC, warns the CCG may not have enough left in its budget to pay practices for existing extra services, such as oral glucose tolerance tests for gestational diabetes and phlebotomy.

He adds: ‘We will be discussing this very issue with the CCG. The LMC will be telling them that if they don’t want to buy these services they won’t get them.’

All CCGs have the ongoing pressure of the QIPP challenge, which requires the NHS to find £15bn to £20bn efficiency savings from 2011 to 2014.

But the first signs remain encouraging from CCGs, although their leaders are pessimistic about whether any increased investment will translate to a rise in take-home pay for GPs.

Dr Farmer says: ‘To be frank, I don’t think GPs are going to make money out of it. They will be doing slightly different things and at the very, very best standing still. But, if you look at systems where you are just constantly standing still and fire-fighting and instead plan to manage that system, you can anticipate crises and reduce their occurrence.’