The Politics of CCGs

How will GPs and Doctors commission NHS services?  This is the big question that will really determine the future of the NHS in England (and will have a substantial impact on Wales, Scotland and Northern Ireland).

But "How" is to a great extent determined by "Who".

The Clinical Commissioning Groups (CCGs) have evolved, and are taking on distinct and different personalities from each other.

History of the CCG

CCGs go back to Margaret Thatcher's day, the Fundholding GP practices of 1990s.  In this case, GP Practices were given a fixed sum of money and had to pay for all of the non-urgent healthcare needs of their patients (well, the more predictable ones) within this budget.  By and large, it worked (in the sense that health professionals created innovative care pathways to keep patients well, which meant they didn't need costly hospital treatment, which meant that care quality remained high but costs went down).

Inevitably, perhaps, a few people exploited the new freedoms (got rid of their expensive patients, failed to pay for treatment today and retired before the care needed caught up with them, etc) and got very rich, and the knee-jerk reaction was to abolish the whole scheme.

A new conservative government tried to introduce fundholding as GP Commissioning Consortia (GCC) in 2010.  GPs would take responsibility for the cost of the care of the patient, and could use any money left over from the budget to spend on developing innovative pathways that keep the quality of care high and basically keep people well instead of sick.

As an idea, it makes sense.  GPs are responsible for making the decisions, so GPs should have to live with the consequences.

But hospital doctors recognised what this would do to hospitals, and demanded a place at the table.  Not just as advisors, but as decision-makers.  GPs said that if someone else was making the decision, then GPs wouldn't take full responsibility for the outcome.  PCTs faced huge redundancy costs so the government capitulated and a CCG won't be authorised unless they have employed enough people from the PCTs they replace, to demonstrate that they have retained experience, and KPMG did a study on the fixed costs of running a CCG and found it to be £1.6million (all in salaries for directors, incidentally), so rather than the election promise of "no top down change in NHS", the Secretary of State for Health has been increasingly prescriptive about the CCGs, leaving GPs bemused as to exactly how much decision-making they will actually have.

Crystallising personalities

Which brings us to today's CCG.

Most GPs just want to get on and treat patients for their ailments, and keep them well.  They don't want to plan, and contract, and monitor.  So many of the GP consortia are led by one GP or Practice Manager with ambition, with a whole lot of GPs and GP practices who don't feel strongly enough either way to say "we want to go in this direction" or even "we don't want to take part".  These GP consortia, or CCGs as they are now, will behave in two distinct ways:

• Sole supplier/ provider: one GP practice will come up with all of the ideas and new pathways, will probably also own the healthcare provider companies that provide the new pathways, and the other GPs and GP practices won't really participate - they will continue to do what they have always done, and when the new pathways are already set up, then they will use them
• One leader, lots of sheep: one GP practice will cajole the others into doing whatever the CCG chair thinks is important; they will jointly set up new pathways but under sufferance, and will refer their patients into the new pathways because they have been told to.

  But some CCG chairs are already working hard to deliver a third way.

• An inclusive model: Encourage GPs and individual GP practices to come up with their own ideas, then the chair and support team support the development of those ideas so that the GP practices are genuinely participating in GP commissioning of new pathways.  This may sound like the "obviously best" model, but it doesn't happen by accident.  Easington CCG is implementing it and has had to employ two GP Practice Support Officers (Agenda for Change 8) to build personal relationships with each practice, encourage them to use the tools of commissioning and cooperating, write the business cases and hand-hold practices to write business cases, and propose policy changes eg to Standing Financial Instructions for the spend of £millions.  It certainly isn't the easy option!

Selling your services to GP consortia and CCGs

Of course healthcare providers and hospitals face a new challenge of selling their services to a new, and potentially more demanding, task master.  The market reforms of the Thatcher era consolidated under Tony Blair, so that commissioners bought the services and providers (hospitals, mental health trusts, community nursing, and a whole host of private and independent companies) sold them.    But prior to 2004, PCTs were typically much smaller (in terms of population covered) than hospitals and hospitals could pretty much dictate what the PCT would have to buy to maintain good relations (Roemer's Law - "a bed built is a bed filled").  2004-2006, PCTs were consolidated into a stronger negotiating position, but for most, behaviour didn't change and they still went along with whatever the hospital said they should.  This tactic has bourne fruit - many ex PCT staff are now employed by hospitals and the ones that commissioned hard are probably the ones that don't have employment.

The GPs have no such concerns.  They can't decommission services because of the number of hospital clinicians in the decision-making process, but they can start to create new pathways.  And very often, they create new pathways because someone (a healthcare provider, eg a hospital or independent company) came and explained what could be done.

This makes it vitally important that any healthcare provider is proactive.  You need to

1. identify your market (which of the above models of CCG, will determine how many GPs are likely to offer their patients the choice to use your service),
2. identify your approach (depending on the above CCG model, who you approach and whether the offer includes a profit share, is provided within NHS, etc), and 
3. follow through (again, depending on the CCG, once your pathway is in place do you need to market heavily in competition with other services, or do you need to ensure that a few very influential GPs advise the other GPs of its availability)

Politics is, as ever, vitally important.