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Is your CCG your friend, or your frenemy?

Imagine you’re a GP; it shouldn’t be difficult, for if you’re reading this article you probably are one… You aren’t an ambitious, management-focused, media-hungry go-getter, but a doctor who wants the best for her patients. Your list size is average, which means that around 1,600 patients are registered with you, and they depend on you to co-ordinate their care, and be their first point of contact, their main provider of care.

My back of an envelope sums estimate that in 2012 the UK NHS budget was close to £110 billion, which was available to look after about 60 million people. That works out at about £1800 for each person, which meant that for an average list, about £2.9 million was available. Scary isn’t it?

Now obviously, quite a lot of this was spent on fixed overheads like Public Health England, and redundancy packages for displaced managers, but let’s ignore these for the moment, because it’s always been the Government and ‘The Centre’ that have determined these. The important point is that since April this year, control of over two thirds of this budget has been handed over to CCGs, to spend on commissioning services for their patients.

The logic underpinning this move has been explicit since the 1990s. GPs co-ordinate their patients’ care, and their referral of these patients determines much of the activity in the community, mental health and acute sectors; ho better to ‘own’ the resources associated with this activity, and use their knowledge, common sense and autonomous professionalism to begin to move activity in ways that improve both the effectiveness and the efficiency of that care?

All the reforms of the past two decades or more have been moving towards this end. GP fundholding, GP commissioning, PCGs, PCTs, and now CCGs, all have been designed to wrest control of activity as much from the politicians as from the large provider organisations, to stop them peddling their vested interests at the public (often through the tabloid media). The logic of all the policies developed over this time have all been pushing in the same direction, albeit with different structures in place to make the policies happen.

So how does this link to the title of this piece? Are CCGs a Good Thing for GPs, or a disaster? I started by pointing out that in theory, you have the power to control the manner in which £2 million or more should be spent on the care of your patients, so I’ll follow that up with two challenges. The first is: don’t you think that you could use that amount of money more sensibly and effectively than it has been spent in the past? Only you know what your patients really need, and with the freedom to be innovative, you could probably think of all sorts of ways of doing things better, more quickly, in more user-friendly ways: it’s £2 million pounds, for goodness sake.

But while £2 million may seem like  a lot to you and me, it’s only a couple of trees in the enormous woods of the NHS. How do we a) maximise its impact and b) minimise the risks to you and your patients?

The strength of general practice lies in individual patient care. If GPs are to be involved in planning and procuring services for entire lists, then they will need ways of working that offer economy of scale and provide insurance against unexpected events (imagine what a cluster of motorway crashes over a holiday weekend would do to the T&O budget, for instance) without destroying the ‘can do’ spirit that has been so integral to their success over the past 65 years.

Where CCGs are genuinely ‘owned’ by their GPs, then the new organisations have great potential. However, they may then expect the ‘corporation’ to offer them support and act on their suggestions often enough to show them overall benefit and maintain their loyalty. They could be seen as GPs’ friends, but ‘with teeth’ - where the relationship needs constant effort and development but the gain (whether in terms of patient care, professional satisfaction, or even primary care development) justifies the pain.

However, if CCGs are either run in a top-down fashion, or driven by political rather than care-based priorities, then it will not take long for the cynicism to emerge. Like the PCTs before them, such CCGs will quickly be seen as foe, whose actions are to be resisted and subverted.

That said, the large-scale leadership developments that seem to be emerging from the new Leadership Academy have never worked before, so it is hard to see why they should succeed this time.

Instead, commissioners need enough interest to be engendered amongst working GPs to persuade them to invest some of their precious time and emotional energy in getting the show on the road, and make it a show of which GPs can be proud. And that won’t happen without effort or resources, either. But with the potential for every GP with an average list to influence local prioirties for million-pound budgets, isn’t that investment worth it?

Dr Jonathan Shapiro is an a former GP with wide experience in clinical, managerial, and academic roles. He works with policy makers, organisations and individuals to develop effective, sustainable systems with integrated clinical and managerial functions You can email Dr Shapiro on