'I find it exhilarating mostly. On the bad days I remember that I would be furious if somebody else were doing this job, because it is a job I have always wanted,' says Oxfordshire CCG medical director Dr Mary Keenan.
A GP for 25 years, Dr Keenan took on out-of-hours work and gave up her partnership last summer because she felt unable to manage it on top of her CCG role.
She is one of hundreds of GPs across England juggling their work in general practice with a new role in commissioning.
From 1 April, 211 CCGs will replace PCTs and become responsible for £65bn of the £95bn annual NHS commissioning budget.
GPs involved in commissioning now face huge responsibilities and difficult decisions, including how to ration services as NHS resources shrink. Like Dr Keenan, many have made personal sacrifices and risked relationships with their colleagues to take on the roles.
Dr David Tooth, pictured right, chairman of Rotherham CCG, south Yorkshire, consulted his practice partners before starting work with the CCG. 'They said yes; it causes upheaval as locums cover clinical work, but they don't cover management responsibilities,' he says.
'I make compromises to manage my time between the CCG and the practice. If I didn't do the clinical work, I would just be another NHS manager and I am not, I am a clinical leader.'
Dr Tooth now works three days a week in his practice and two days on the CCG, but in the early stages, he gave up additional days to the commissioning role.
Dr Fiona Armstrong, chairwoman of Swale CCG in Kent, admits: 'There is a real tension between clinical commitments and the commitment to CCGs, with many GPs having to drop clinical sessions.'
Commissioning GPs have worked hard not only to maintain relationships within their own practices, but also to build engagement between their CCGs and the local primary care community as a whole.
Dr Keenan says: 'We are trying really hard to make sure we are creating a member organisation of 83 practices, and making it a dialogue, rather than top-down.'
Bexley CCG chairman in south-east London, Dr Howard Stoate, says the response from local GPs has been positive. 'We haven't had overt animosity,' he says.
GPs 'make their views very clear', but even opponents of the NHS reforms 'don't hold me responsible for government policy', he adds.
Dr Keenan says: 'It is not always comfortable because people have different opinions. But I am always encouraged when there is energy in the room rather than apathy.'
|CCGs in the driving seat|
Learning the ropes of commissioning and working towards securing authorisation from the NHS Commissioning Board has been tough, GPs admit.
But the hardest decisions for CCGs are yet to come, warns Dr Tooth. 'The difficult part is going to be providing services with ever shrinking resources.
'I don't think any of the decisions have been easy,' he adds. 'The reorganisation aspects have been very hard. What has happened to the NHS management structure has been pretty ugly, with large numbers of people unsure about their jobs.'
So, have the sacrifices and tough times been worth it?
'It is massively demanding, but it is rewarding,' says Dr Stoate. 'We really are able to make decisions and we can see that it becomes reality.'
Dr Helen Tattersfield, pictured right, chairwoman of Lewisham CCG in south-east London, says that initially at least, the group 'made big differences and had influence'.
'We worked with the council and the PCT. New pathways reduced unplanned COPD admissions by 16%, MMR coverage at two years went from 80% to just over 90% in a year - from 29th in London to 13th.'
Many other CCGs report major cost-saving and health improvement successes, including cutting prescribing costs and emergency referral rates, and delivering dramatic improvements to stroke care.
Quite simply, many GPs believe it is common sense to involve them in commissioning. Dr Tooth points out: 'GPs talk to patients on a daily basis and know what the service is like, so it makes sense for them to be on board and be held to account.'
But, perhaps inevitably, some have found CCG roles frustrating. Dr Gary Marlowe, a clinical board member at City & Hackney CCG in east London, admits he feels like throwing in the towel. 'In common I would imagine with most GPs on CCGs, I am swamped by documents and initiatives. I joined to keep the focus on patients and to mitigate the worst aspects of the Health and Social Care Act. Listening to local populations and making apolitical value-for-money decisions, holding as the prime arbiter clinical need, seems to have been thrust aside.'
Despite early successes, Dr Tattersfield has also become disillusioned after moves to shut local hospital departments were set in motion without consulting the CCG.
'I have no influence. I have not met a clinician who backs the proposals. The whole point of these reforms was local people knowing best for local people,' she says.
Despite the doubts, many GPs involved in CCGs remain convinced they can succeed. 'GPs have always delivered beyond expectations and I am sure we will continue that with clinical commissioning,' says Dr Amit Bhargava, clinical accountable officer at Crawley CCG, West Sussex.
Commissioning GPs will certainly be exposed when making tough decisions in future, but many remain enthusiastic and relish the chance to play a key part in targeting NHS resources where patients need them.