The King’s Fund and Nuffield Trust are examining commissioning in six study sites and carried out 74 in-depth interviews, 18 direct observations and had 232 survey responses from practices.
The results in CCGs: Supporting improvement in general practice found a fifth of practices predicted their change in behaviour would have a negative effect on patients. The majority said the scale of change had been small.
The report says: ‘This suggests that CCG leaders have some distance to go before they are able to give member practices confidence that being part of a CCG will benefit their patients.’
The majority (59%) of survey respondents were unsure about the effect on patients that would result from changes to their referral rate, referral pathways, prescribing patterns or other clinical practices deriving from their being members of a CCG. A slightly greater proportion predicted a negative impact than a positive one over the next 12 months (19% compared with 16%).
The report adds that it was ‘striking’ that a large majority of the GPs who responded to the survey believed that CCGs have a legitimate role in influencing member practices in terms of their referrals, prescribing, access issues and patient experience. A smaller majority also agreed that CCGs have a legitimate role in influencing the quality of care provided by practices, such as through oversight of scores achieved in the QOF.
Qualitative work suggested that this view is partly due to a feeling that ‘somebody’ needs to take responsibility for these issues and that, under the new system, it would be better for it to be clinically led CCGs that do this than the managerially led area teams of NHS England.
The report’s summary says that the issue of CCGs’ role in supporting quality improvements in general practice remains a ‘sensitive’ one. It adds: ‘There are differences of opinion on the question of how exactly CCGs should undertake this role.’
The report continues: ‘CCG leaders and members alike placed considerable emphasis on CCGs playing a supportive role, facilitating change rather than imposing it. However, NHS England area teams will be reliant on close assistance from CCG leaders to perform the area teams’ role as contract manager adequately.
‘CCG leaders may therefore find it difficult to distance themselves entirely from more robust performance management activities in cases where persistent performance problems exist in general practice.’
The report says CCG leaders will need to strike a delicate balance between engaging local practices and challenging them when appropriate. The risk is that, in some areas, neither CCGs nor area teams will perform the role effectively nor provide the necessary leadership, and that the partnership between them will fail to create the much-needed stimulus for change.’
The research also found a gap in perception between CCG leaders and member GPs. Leaders were more likely to think the CCG was owned by its members, decisions reflected members’ views and that clinical relationships had been improved.
Holly Holder, fellow in health policy at the Nuffield Trust, said: ‘There is a great deal of support for what CCGs are trying to achieve: to become locally driven decision-making bodies that provide better care for their populations. However, in order to reach that goal, CCGs will have to sustain the support of their membership and demonstrate how participation from local GPs adds real value to their work. CCG leaders should know which areas of clinical practice GPs perceive to be legitimate spaces for CCGs to influence, and which strategies could risk disengagement.’