CCGs: Why some GPs are growing 'weary' with commissioning

The Nuffield Trust has been following the progress of CCGs for the last four years. Holly Holder outlines what the research tells us about GPs' engagement with the commissioning process.

CCGs were so four years ago. It’s all about sustainability and transformation plans now.

This might be what it feels like in the NHS at the moment but before we rush to create the next new thing, let’s review the balance sheet. CCGs have succeeded in engaging more GPs in commissioning than their predecessors PCTs. This is no small task.

After four years of following the same six CCGs through their journey from authorisation to the position they are in today, we can see that they have matured as organisations and have established themselves as an influential part of the local health economy. Overall levels of engagement have stayed broadly the same during this period, with around two-thirds of CCG members felt highly, moderately or somewhat engaged.

However, there are also a group of GPs who appear to be losing interest in commissioning; particularly those without a formal role.

This year, we asked our survey respondents ‘Has anything changed over the past 12 months that has made you feel more/less engaged?’ Here’s what some of them told us:

‘Things are out of our hands’

‘So much changes that is out of our hands that anything we plan is usurped’ (GP and CCG governing body member)

Since formally receiving their statutory responsibilities in April 2013, CCGs have been asked to respond to various policy initiatives from NHS England and the DH; the Better Care Fund, co-commissioning and Sustainability and Transformation plans to name but a few.  Therefore, it’s perhaps unsurprising that some GPs felt as though the commissioning agenda was being set nationally, and that there was a ‘political agenda, not locality as previously led’.

Others mentioned financial pressures, with one GP stating ‘budget cuts [are] disillusioning me’.  That being said, there was also a general agreement between our case study CCGs that these changes were necessary, and a sense from some GPs that they appreciated CCGs’ attempts to ‘future proof’ them and help make them more sustainable in the future.

Are grassroots GPs engaged?

‘Membership organisation? They do their own thing’ (GP without a formal role in their CCG)

CCGs are membership organisations and therefore, should be responsive to the views of their GP members. However, there are some GPs, particularly those without a formal role in their CCG, who feel increasingly distanced from their CCG. 

Only one-fifth of those without a formal role felt that they could influence the decisions taken by the CCG and this has deteriorated in the past two years.

Some GPs told us that at times they felt as though decisions had already been taken by the CCG and that their involvement was reduced to a ‘tick-box’" exercise. Other GPs described a lack of clarity around the CCGs’ strategy and how communication should be improved.

This isn’t to suggest that all those involved in CCGs feel this sense of separation. 83% of survey respondents felt as though the CCG had a significant role in their local area. One GPs without a formal role felt the CCG was ‘cohesive and collaborative’, while another GP in a leadership role commented that their CCG had helped ‘shape service priorities’.

Time pressures

‘Less and less time’ (GP and CCG practice member representative)

The pressures facing general practice are well known. From the beginning, CCGs were aware that in order to keep clinical engagement, they would need to backfill GPs’ time for attendance at meetings and try to communicate in the most efficient way possible.

However, there are still a number of GPs for whom undertaking their clinical day job whilst participating in commissioning has become too much. One GP reported feeling ‘weary’ with commissioning and another said that they had ‘just lost enthusiasm’ as a result of workloads.

Even 40% of GPs in leadership roles said that they did not have the time necessary to fulfil their role in the CCG and 36% said that it was having a negative impact on their clinical practice.

On a far more positive note, a large proportion of those with a formal role in the CCG said it made their work life more fulfilling (88% of governing body leaders and 38% of member representatives, GPs only) and the majority of those who have a leadership role plan to stay put for the foreseeable future (71%, all respondents).

Some reported that their ‘confidence and knowledge of how commissioning works has continued to improve’. Others referred to communication and engagement improvements as a result of new GP provider groups and improvements the ways in which the CCG interacted with practices. And as is outlined in the full slideshow CCGs appear to be having a positive impact on relationships between practices and working as part of multidisciplinary teams.

What does all of this tell us?

When we first embarked on this research in 2013, we asked ourselves what was an appropriate or suitable level of engagement. Of course, CCGs do not require the involvement of every single GP but they should be acutely aware of their critics.

It is clear that one of the main objectives of CCGs – to increase clinical engagement in commissioning – is still falling short. All GPs should understand what is expected of them and feel able to influence the decisions in their area, including those without a formal role in their CCG.

At a national level, policymakers should ask themselves if, with all the requests being asked of CCGs, is it any wonder that some GPs are left pondering who is actually in charge of commissioning in the NHS? If NHS England wants to see local leadership in commissioning, they’re going to have to give CCGs the time and resources they need to properly engage with their members.

Read the full report Has clinical commissioning found its voice? GP perspectives on their CCGs

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