Clinically-led commissioning in the English National Health Service: The challenges ahead.

London School of Hygiene and Tropical Medicine & Manchester University Research team: Dr Kath Checkland (PI), Dr Anna Coleman, Dr Christina Petsoulas, Dr Julia Segar Dr Imelda McDermott, Ms Rosalind Miller, Dr Andrew Wallace Prof Stephen Peckham, Prof Stephen Harrison

The latest health care reforms in England

The Reforms Old SystemNew system (April 2013)  PCTs  SHAs  Managers driving commissioning  CCGs  NHS Commissioning Board  Clinicians (GPs) driving commissioning

The Reforms  A continuation of primary care-led reforms in the past 20 years (GP fundholding, total purchasing, primary care groups/trusts, practice-based commissioning).  Rationale: to put clinicians in charge of commissioning. They make decisions about care they should also be in charge of the money.  White paper (Liberating the NHS, 2010).  April 2011: ‘Pause’ (for consultation) in the parliamentary passage of the Health and Social Care Bill.  Health and Social Care Act 2012 (after feedback from the Pause).

The project  Aim: explore the experiences of emerging CCGs  Objectives:  What factors have affected the development of early CCGs?  What approaches have they adopted to being a membership organisation, developing external relations and commissioning/contracting for services?  What lessons can be learnt for future development and support needs?

Methods  Fieldwork September 2011 – May 2012  Eight detailed qualitative case studies (selection criteria: size, geography, stage of development).  Interviews with GPs and managers (96)  Observation of meetings (146)  Analysis of documents  National web surveys and telephone interviews with a random sample of CCGs.  Response rate: 41% and 56%

Main findings I  History of previous groups important (e.g. many CCGs built on existing PBC groups or previous primary care groups).  Key individuals played a crucial role in generating enthusiasm. Difficulties in recruiting new GP leaders.  A wide range of CCGs (defined by e.g. size, organisational model e.g. Assurance body, operational bodies, Council of Members, locality groups, Advisory group of clinicians, managers and external representatives).

Main findings II  Many policy areas were unclear which created confusion and uncertainty for the new CCGs.  CCGs are anxious not to lose capable and trusted personnel and existing relationships.  Broad support for greater clinical involvement in commissioning but question about the need for such large scale reform.  Lack of clarity about what ‘being a member’ of CCGs means.  Uncertainty about commissioning of primary care services.

Challenges  GP time constraints  Need to clarify relationship between CCG and its members: degree of autonomy vs. sufficient accountability  Tension between need for policy guidance and freedom of CCGs to develop their local organisations.  Need to clarify relationship between Commissioning support services (CSS) and CCGs.  Need to manage potential conflict of interests of GPs as providers and commissioners.