At the start of this month, the NHS in England underwent a seismic shift as the final remnants of PCTs handed over responsibility for commissioning patient care to 211 CCGs.
CCGs now oversee £65bn of the £95bn NHS commissioning budget. The government believes the groups will improve patient care.
It says putting GPs and other clinicians in charge of commissioning decisions will lead to a better use of resources and raise standards across the country.
But what do GPs themselves think? Will CCGs improve the NHS in their area? Are they involving local GPs in decision-making? And how are they engaging with practices to monitor and improve performance in primary care?
According to a GP poll of more than 600 doctors, less than a quarter of GPs believe the switch to CCGs from PCTs will improve the NHS in their area.
Just 24% said the move would improve the NHS locally, and 57% said it would not.
Perhaps part of the reason for this scepticism is that GPs are cynical about CCGs' creation. Almost three-quarters (73%) of doctors polled said they thought the new bodies had been set up to take the blame for rationing of NHS services.
A GP partner who works for a CCG in the north east, but did not want to be named, said: 'Because the changes are coming at a time of reduced resources the CCGs will inevitably fail in delivering better care.
'The pressure to save money and go to private providers is likely to reduce quality and increase fragmentation and confusion, and increase administrative workload.'
A GP partner in Yorkshire, who also wished to remain anonymous, said: 'In theory, having GPs more involved is positive, but a management structure is still required. I also have no confidence that GPs will have significant choice over the decisions they make in the context of large resources cuts.'
Despite the concerns about funding, 40% of GPs rated their CCG as excellent or good on its use of available resources when asked to assess the groups' performance so far.
Transforming local NHS
GPs were also, on the whole, confident that their CCGs were ensuring high quality care for their patients.
Some 44% of GPs said their CCG was excellent or good at providing best possible care for its population, compared with just 19% who said it was poor or very poor.
Dr Robin Jackson, a GP partner and a member of the governing body at Lancashire North CCG, said: 'We are transforming the NHS locally. All of our patients will benefit. The weary old naysayers and politicos in the BMA should come and have a look at what real 21st century medicine is.'
But not all doctors agreed. One GP partner from west London said his CCG was not supporting GPs as advocates for the community and was not 'taking ownership' of the problems GPs face.
'CCGs are on a totally different platform, being led by the PCT team, who have different hats on, but are still not supporting the GPs in their task to provide best professional care to meet the unmet needs of the community,' he said.
Almost half (44%) of the doctors polled said their CCG rated satisfactorily on its approach to performance management of practices - although there was some concern about the level of work the change to CCGs had involved for practices.
One partner said: 'A lot of unnecessary administrative tasks for practices have been required. The situation is a lot worse than when the PCTs were in charge.'
CCGs were rated less well on transparency. More than one third of the GPs polled said the transparency of decision-making by their CCG was poor.
Only 14% felt the transparency of decision-making was excellent, and 34% rated it poor or very poor.
Dr Chris Mackenzie, a GP partner in Bromley, Kent, said: 'GPs should be working as doctors looking after their patients and not trying to run budgets. There are too many conflicts of interest.'
Dr Grant Ingrams, a GP partner, deputy chairman of his locality group and IT lead for Coventry and Rugby CCG, warned that CCGs' hands will be tied on decision-making.
'I suspect they will spend all their time implementing government policy, forcing practices to comply with QIPP and working out which service to reduce or stop next,' he said.
'The "NHS competition regulations" will result in CCGs being unable to commission in the best interest of their patients, but only in the best interest of commercial companies.'
Involving local GPs
Of the 600-plus GPs polled, of whom 18% held a position with a CCG, the overall picture is that GPs are reasonably happy with their engagement by CCGs.
Almost half (51%) said their CCG was either excellent or good at involving local GPs.
But locums and sessional doctors responding to the survey expressed concern about their involvement. Among sessional GPs, almost a third (30%) rated their CCG's involvement with local GPs as poor or very poor.
One GP locum from west London said: 'There are considerable numbers of GP locums in each CCG area. Many CCGs do not include them in their boards at all. GP locums remain uninformed of new developments, why?'
A salaried GP, who did not want to be named, said: 'As a GP non-principal, but with more than 10 years' local experience, I have no links with the CCG despite wishing to have some involvement.'
It is very early days for CCGs, but it is clear that they face significant challenges in terms of the resources they have available and the difficult decisions this inevitably means they will have to make.
How they approach and deal with these challenges over the coming years will determine whether they are able to deliver an improved NHS.
'We want feedback from local staff to help us develop'
Dr Mary Keenan, medical director at Oxfordshire CCG, is positive about the impact that her CCG has made so far.
She says GPs are well-represented on her CCG's board, which will give it 'the best chance of managing the huge financial challenge we face'.
Dr Keenan says her CCG has reached all GPs. 'We are working hard to strengthen the links with all our GP members, whether principals, sessional or salaried GPs,' she says. 'This is bearing fruit in the development of individual locality plans within the county.'
The CCG has a 'maturing relationship' with its local health and wellbeing board, Dr Keenan explains, which means they can have 'more robust conversations about the best use of resources'.
She adds: 'Oxfordshire CCG designed a survey to seek the views of frontline staff across the health and social care landscape in the county and have been pleased with the response rate.'
'We want to protect local people'
Lewisham CCG chairwoman Dr Helen Tattersfield admits she has questioned whether there is any place for local clinical commissioning in the health service following the NHS special administrator's decision to close services at Lewisham hospital.
But her response and that of other CCGs has been that there undoubtedly is. Despite the sense of frustration over the future of Lewisham hospital among local clinicians, vaccination rates in the borough have increased by 10% since the CCG's formation, and prescribing has improved dramatically. 'We still have a considerable role and we want to protect local people,' Dr Tattersfield says.
'Although we argued our case intensively on Lewisham hospital, if we do not win the argument we can make sure that residents are protected, we can influence how changes take place.'
Decisions taken by her CCG are made with proper engagement and consultation, she says. 'We don't make decisions and then tell people about them. We've learnt over the past 18 months that when you think something might be an idea, that's the time to ask people about it.'
The CCG's involvement with local GPs has been good, as has its work on practice 'improvement' - Dr Tattersfield says she prefers not call it 'performance management'. As for whether she thinks CCGs have been set up to take the blame for rationing of NHS services, 'That depends on what day you ask me that question,' she says.