Complex infrastructure and excessive control threaten commissioning group success

The ability of clinical commissioning groups (CCGs) in England to “rebalance” the NHS risks being undermined by the complexities of the new commissioning architecture, competitive behaviours among GPs, and an overly controlling National Commissioning Board, a senior policy analyst at health think tank, the King’s Fund, has warned.

Speaking at a Westminster Health Forum Keynote Seminar in London on13 June, Nick Goodwin said that GPs were ideally placed to “rebalance the system” and create a more primary and community care led service, without which the NHS would be unsustainable. “As a principle, it’s clearly a good move,” he said.

But he wondered how easy it would be to forge effective and collaborative partnerships among all the different bodies that were now part of the new NHS landscape.

“As the architecture has developed, the original idea of a fairly light touch National Commissioning Board, and a whole load of CCGs, is now a very much more complex picture,” he said. “How those relationships will pan out is quite problematic,” and commissioners would need “to tread carefully.”

CCGs needed the flexibility to innovate and do things differently, he said, but feared that they might not be granted it because the National Clinical Commissioning Board would control the primary care budget, he suggested. “The degree to which the system will let go in order to allow CCGs to do their job most effectively is very important and needs a lot of work,” he warned.

But relationships with peers were also key, he said, and how well individual practices would feel part of CCGs and properly represented by them, was “at the heart” of success, he suggested.

King’s Fund research of GPs’ views of their colleagues in managerial positions, carried out a decade ago, indicated widespread distrust, with most branding them “opportunists,” “megalomaniacs,” “put upon,” or as experiencing “a mid-life crisis,” he said.

GPs also needed to think differently and shift their focus from services for local communities to their wider commissioning responsibilities, he said. And he pointed to “quite a lot of competitive behaviours,” displayed in the tendency in the early stages of CCG development to forge provider rather than commissioning alliances.

Laurence Buckman, who chairs the BMA’s GP Committee, said that the reforms were taking up a lot of valuable time and effort, and GPs needed to be supported so they could take time away from practice knowing that patients would still be seen. GPs also needed “to be encouraged to see the bigger picture,” he said.

“This is about much more than buying and selling. They mustn’t see it as a nightmare, but equally, they mustn’t see it as propaganda either,” he said, adding that all too often the information issued by primary care trusts was “so full of jargon” it was “completely impenetrable.”

Not only did GPs need good information to understand what the changes meant for them and their patients, but they also needed good quality data on which to base commissioning, he said. “But I have to tell you the data is junk,” he declared, and worryingly, it was still being used to inform budget allocations up and down the country, he said.

And for the changes to succeed, primary care staff needed to feel included, he said. But, he contended, “most of our staff don’t feel part of the landscape, because in my view they have been deliberately excluded.” He found this “completely baffling.”