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At what point does GP-led commissioning stop being GP-led?

The investigation last week by Pulse’s senior reporter Jaimie Kaffash into the number of GPs stepping down from CCG boards rightly attracted plenty of attention – including a rare piece of joint national coverage with GP magazine, who conducted a similar investigation, in the Daily Mirror.

While some degree of turnover is of course to be expected, it is certainly striking that so many enthusiasts involved with commissioning at a senior level, including at least four CCG chairs, have stepped down within the first six months of assuming commissioning responsibility.

But the investigation also threw up another startling statistic.

Out of 949 board positions across 74 CCGs, just 406 were filled by GPs. That’s only 43% (and while our sample looked at only a third of CCGs, GP magazine’s investigation, conducted entirely separately, came up with the same figure).  

A relatively small proportion then, and a falling one. A similar Pulse investigation in July 2012, across 100 CCGs, found that GPs filled 49% of CCG board seats. The exact proportion may be out by a percentage point or too, but the trend is clear: GPs are now very much in a minority on CCG boards, and their voice is getting quieter.

Even outside the profession, those figures have caused some consternation. The health commentator Roy Lilley said: ‘Astounding, as these reforms are all about docs being in the driving seat. We are well on our way back to PCTs.’ Dr Gabriel Scally put it even more pithily: ‘Whatever happened to giving control to GPs?’

The decline in GP representation is perhaps the inevitable consequence of the watering down of Andrew Lansley’s vision over the past three years. Initially we had GP consortia, with general practice firmly in the driving seat. Then we had the NHS Future Forum’s fudge of clinical commissioning groups, with consultants, nurses and even lay people given much more of a voice. Now enthusiasm even among commissioning pioneers appears to be dwindling.

The temptation for many GPs, particularly those sceptical of the reforms in general, may be to shrug their shoulders. Many grassroots GPs stopped regarding CCGs as GP representative bodies a long time ago. But general practice’s declining power on CCG boards should matter to every GP in England, and for two reasons.

Firstly, whether or not you support the concept of clinical commissioning, for it to be a success, for it to actually make a difference, it must fully involve general practice. Only if a sufficient number of GPs – preferably the coalface doctors who wouldn’t normally get involved in this kind of thing – take part in decision-making will clinical commissioning actually help improve the fortunes of the NHS. Given the NHS reforms have already cost the health service hundreds of millions of pounds, simply recreating what went before should not – cannot – be an option.

And secondly, regardless of who actually makes decisions on behalf of CCGs, it is GPs who will be held responsible and who will have to defend them. If the general public can tell you one thing about the NHS reforms, it is that GPs are now holding the purse strings. Never mind who sits on the board; CCGs are membership organisations constituted of GP practices, and GP practices alone. Chances are, over the next few years your CCG is going to have to make some pretty difficult calls – on rationing, on restructuring – and you and your practice will be held accountable for them.

Like it or not, in the public’s mind GPs now run the NHS. For as long as that continues to be the case, it’s essential that practices have a direct say in the decisions which actually matter.

Steve Nowottny is the editor of Pulse. You can follow him on Twitter @stevenowottny.