In April 2013, CCGs were introduced to replace primary care trusts as the commissioners of most services funded by the NHS – and they now control about two thirds of the NHS budget. The key change is that clinicians play a greater role in deciding how funds are spent on commissioning services and all general practices in England are legally obliged to be a member of a CCG.
Not all GPs are involved with their local CCGs and therefore the extent to which GPs are actually engaged in making decisions about the management of the NHS varies. Kate Adams, a GP in Hackney, thinks overall engagement between GPs and CCGs is growing under the new arrangements. “GPs are working more closely together between practices and there is closer working between doctors and managers, which is a good thing,” she says. GPs have an important role to play in giving “clinical input to redesigning care pathways”, she adds.
According to a report by the King’s Fund and the Nuffield Trust, GPs who have got involved with CCGs have seen a definite impact – 66% of GPs who led CCGs felt that their CCG was “owned” by its members, compared with 35% of those without a formal role in the CCG.
Nicholas Hicks is chief executive of Cobic, a consultancy advising commissioners and providers on outcome-based healthcare services, which aims to secure “both value for money and better outcomes for patients”. He thinks that GPs will be instrumental in changing the way services are commissioned: “GPs are far more involved with commissioning than before and they bring fresh perspective, not least because they are less inclined to accept central directions that they do not believe make sense.” He adds that: “A fresh eye has meant that CCGs are far more open to adopting innovative approaches to commissioning than were the majority of their predecessor PCTs.”
Rick Stern, chief executive of the NHS Alliance, thinks the strength of the CCGs is their clinical focus and “different style and approach in leadership”. PCTs, he says, were felt to be “too distant and bureaucratic, and the real test for CCGs will be to show they are radical and different, and a break with the past.”
CCGs have two main roles – commissioning services and supporting improvement in general practice.
There is the opportunity here, Adams says, “to address the bigger issue of society, health and wellbeing – GPs understand how important this is and how to make an impact on people’s lives.”
Hicks agrees: “A growing number of CCGs want to commission in a different way – they are taking steps towards letting contracts that pay providers on the quality of the outcomes they achieve for people that use the services rather than on the volume of activity.”
Traditionally, PCTs and CCGs place one-year contracts with providers such as hospitals in which the value of the contract is determined by the number of patients a hospital treats. Under the outcome-based model, Hicks explains, the provider (which may be a new alliance of hospital, community and social service providers) is given a “longer-term contract, a base sum of money for the care of a group of people (such as older people, people with drug and alcohol problems), and money for improving the outcomes for the people using the services.”
How services are commissioned is integral to managing change and we need a different style of commissioning, says Rick Stern. “CCGs must work with their patients and the wider community and work through difficult decisions – there will be massive problems with budgets in years to come and we need to look at transforming the way healthcare is delivered – this is a big and complex debate.” And it’s a conversation that the GPs are best able to lead, he says. “Are people willing, for instance, to let go of the sacred position of their local district hospital and have more services offered in the community and in specialised centres?”
Trying to improve and measure outcomes for people who use NHS services will be an area that every CCG will be working on but it will take time. As Adams says: “The future is about transforming services – giving benefits to patients and freeing up money for things that really matter – preventative and community health and wellbeing.”