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Restricting referrals is not what commissioning is about

If CCGs are to succeed, they must look beyond limiting GP activity, says Dr Richard Ma.

Some clinical commissioning groups are looking at GPs' referral rates, A&E admissions and prescribing habits – and in some cases, it seems they are even judging practices on their suitability to join the CCG by these kinds of performance criteria.

But a GP's decision to refer depends on a complex set of factors. It may reflect an individual practitioner's knowledge and skills, or the resources available at the practice such as access to special skills, diagnostics and support services. Some patients in affluent areas may demand to be referred, whereas deprived areas may have higher levels of health need and morbidity. Judging a practice by referral rates and prescribing habits would miss many other markers that denote quality.

A survey by the National Primary Care Research and Development Centre on practice-based commissioning activity a few years ago showed many GPs had organised themselves into consortia, and that reducing referrals to secondary care was a typical goal, partly achieved through referral management schemes. Reflecting on referrals and prescribing may be one way of making more effective use of healthcare resources as part of the QIPP agenda – but by concentrating on GP activities, are CCGs really commissioning?

A leap of faith

The term ‘commissioning' has been used loosely throughout its history. The Department of Health's own guide to commissioning describes, in essence, five stages to the commissioning cycle: assess needs, plan, contract, monitor and revise. The stages are complex, they are not always addressed sequentially and some may take place concurrently with others. CCGs, through referral management, might touch on the needs assessment and evaluation stages, but it seems a leap of faith to expect them to implement the entire cycle, and a monumental task to replicate this for every care pathway with local healthcare providers.

Is it the role of CCGs to review GP performance? The remit of a CCG includes looking at its local healthcare economy for opportunities to create more effective clinical pathways and better care for patients, and also making efficient use of healthcare resources. It is still unclear whether they have any legitimacy in performance managing individual practices – this used to be the role of PCT medical directors and annual contract review teams.

When PCTs are abolished in 2013, many of their commissioning activities will be passed on to CCGs or local authorities. CCGs will need technical support for commissioning activities, including public health professionals skilled in conducting health needs assessments and evaluation, data analysts to assist in health service activity and validation, and skilled managers who are able to procure and negotiate favourable contracts.

By focusing solely on GP activity, CCGs are missing opportunities for better commissioning of care pathways. A McKinsey report in 2009 suggested 75% of NHS spending was on hospitals and community services, and it gave a list of activities that could increase productivity – most of them related to secondary care and community services. Validating, monitoring and appraising secondary care activities for cost-effectiveness should be essential parts of commissioning. If CCGs are to succeed, they need to accept clinical leadership has a role in all parts of the commissioning cycle.

Dr Richard Ma is a GP in Islington, north London