Viewpoint: Clinical commissioning in real danger of becoming smothered

The NHS Commissioning Board (NHSCB) has authorised 34 new organisations - called clinical commissioning groups (CCGs) - to commission healthcare services for their communities, writes BMA deputy chairman Dr Kailash Chand.

Dr Kailash Chand: 'We are hearing worrying reports that some CCGs are developing inappropriate constitutions.'
Dr Kailash Chand: 'We are hearing worrying reports that some CCGs are developing inappropriate constitutions.'

They are the first of 211 CCGs that will from 1 April 2013 be responsible for up to £65bn of the £95bn NHSCB budget. All 8,000-plus GP practices in England will be members of a CCG, putting the bulk of the NHS budget in the control of GPs for the first time.

During the passage of the legislation much prominence was given to clinicians so that they take greater responsibility for commissioning care. However it already seems that this key plank of the reforms is off to a creaky start.  The idea of clinically led commissioning was always laudable. Could anyone at the time really disagree with doctors having more control to shape services for their patients?

However, as CCGs pass through the authorisation process – the process by which the NHSCB deems a CCG ready and able to take full statutory responsibility for commissioning from April 2013 – there are pressing concerns about the level of genuine engagement with clinicians on the ground. 

Inappropriate constitutions

We are hearing worrying reports that some CCGs are developing inappropriate constitutions and are pressurising GPs to ‘sign up’ to these documents. And in the process, GPs are becoming increasingly disillusioned in the development of their CCGs.

Furthermore, as part of authorisation, CCGs are required to provide evidence of engagement with and the support of member practices in order to achieve authorisation, including evidence of member practices signing up to the CCG constitution. However, the evidence required for authorisation varies unacceptably between CCGs and, in many areas, CCG engagement with practices is just not sufficient.

This issue is important as the relationships between member practices and CCGs in these early stages of development will determine the level of genuine, wider clinician involvement in commissioning decisions in the future. There is a risk that as GPs become increasingly disillusioned, the new structures will simply replicate the old (at huge expense), with no sense of ownership amongst the wider profession for the decisions being taken on their behalf.

Should our fears be confounded then we are on a long and unknown path that could see these groups in five to 10 years continue to operate without the necessary involvement and engagement from GPs up and down the country. Without this, can these groups ever do what they originally set out to achieve? Or will we see by 2017 a series of groups that are operated by an enthusiastic minority, disconnected from and unaccountable to the rest of the profession; disheartened GPs and a health service that is struggling with its organisation.

The focus for CCGs needs to be on ensuring we have robust, successful organisations and that if this takes more time, then so be it. There should be no stigma attached to taking longer.  What is needed is further clarity in certain areas, and in particular around the flexibility in the timeframes for CCGs authorisation.  The national-level message is that this can happen any time from April 2013, when CCGs are ready, but some CCGs are pressing ahead with authorisation in April even if they may not be ready – is this sensible? 

There is still time to make clinical commissioning work, but it is in real danger of becoming smothered by a toxic combination of poor implementation, GP disengagement and NHS cuts. The new health secretary Jeremy Hunt, has much to reflect on. And he starts from a low vantage point with a steep hill to climb on this huge NHS curve.  For him, this represents a real first challenge. He must take action urgently to address the implications of the rushed authorisation phase that could undermine the whole project. And on funding, he must show his metal by fighting to protect the NHS budget so that CCGs do not simply become the vehicle by which to cut back our health service.

* Dr Kailash Chand is BMA deputy chairman.

* Three quarters of CCGs authorised with conditions

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