Clinical commissioning groups (CCGs) are increasingly merging, becoming reliant on support from private consultancies and struggling to hold meaningful elections, a GP investigation has found.
The findings show CCGs face an uphill struggle to achieve authorisation and prepare to become statutory organisations from April 2013.
Responses from 84 PCTs to a Freedom of Information request suggest that most PCT areas in existence before NHS restructuring began in 2010 are now covered by a single CCG.
Most CCGs have held elections to choose board members, but many have struggled to find enough candidates to contest them fully. Many CCGs have spent heavily on development and commissioning support from private companies, with some investing six-figure sums.
GPC guidance published last year called on CCGs to hold elections to choose board members on a 'one GP, one vote' basis. All but two of the 84 PCTs that responded, covering 159 CCGs, said democratic elections had been held.
But these figures do not tell the whole story. London-based sessional GP Dr Liliana Risi says it is 'quite common' for CCGs to interview for sessional GP posts on their boards, rather than allowing every GP to stand for election equally.
Other areas have been undermined by a lack of candidates. Fylde and Wyre CCG in North Lancashire cancelled LMC-run elections after just 10 names were put forward for 10 posts.
Some GPs say this lack of candidates has allowed GPs who have historically held power locally to be voted unopposed on to CCG boards.
Stockport LMC chairman Dr David Gilbert says that at his local CCG, of eight board places available, just six were filled, all by GPs who had been involved in practice-based commissioning.
NHS Confederation deputy chief executive David Stout says more work needs to be done to assess how the elections have gone: 'You could get the old guard doing the same old thing, however this could be a good thing. How does it feel on the ground? No one has tested that.'
Since becoming established in shadow form, CCGs have looked to private companies to support their development.
GP's investigation has found that at least 29 CCGs have already used private companies for support, spending up to £400,000. Most were using such companies for developmental, rather than commissioning, support.
A further seven were getting support from their PCT cluster. In Buckinghamshire and Oxfordshire, the cluster is 'leading the development of a commissioning support service'.
GPC negotiator Dr Chaand Nagpaul warns that the use of any support organisation, even PCTs - which could become private once clusters dissolve as the NHS Commissioning Board (NCB) takes shape - could lead to dependence on paid-for NHS management support.
'Large outsourcing will disempower GPs. They will be at the mercy of the ethos of the external commissioning support services,' he says.
Mr Stout disagrees, saying that using private companies is vital to the start-up of organisations such as CCGs. 'In terms of developmental support, most organisations would look outside themselves,' he said.
Mr Stout says it is no surprise to hear CCG numbers are falling. GP's investigation found 52 of the 84 PCTs that responded now have just one CCG in their area. A total of 18 of the rest have two or three CCGs. A handful have far more, such as Hampshire and West Sussex, which have eight.
He says: 'Many CCGs reconsidered their configuration and merged when they realised the £25 per patient management allowance wouldn't spread very far.' He adds that there were likely to be about 200-250 CCGs at the time of authorisation - one or two per PCT area, with more in rural areas.
Dr Nagpaul says changing CCG numbers suggest many are far from ready for authorisation and 'call into question how CCGs can be fully prepared to go live in 2013'.
Co-lead of the NHS Alliance commissioning federation Dr Shane Gordon's North East Essex CCG is one of three in his local area. 'We have no plans to change but I can understand why some CCGs have chosen to aggregate,' he says. His CCG was making the most of its management allowance by federating with three others.
If CCGs are not ready to take on full statutory responsibility by April 2013, GPs fear commissioning may be run instead by outposts of the NCB.
Mr Stout believes neighbouring CCGs could also be handed responsibility for commissioning services on behalf of those yet to achieve authorisation. But given that many CCGs are struggling with their own responsibilities, it seems unlikely many will be ready anytime soon to help out their neighbours.