As only 22% of CCGs have a GP as accountable officer, there are those who believe that CCGs are simply management run organisations supported by a few enthusiastic GPs – PCTs in all but name.
Many of those working in CCGs would refute the suggestion, pointing to the fact that they are a membership organisation, and that the GPs are not supporters but the real engine of the CCG.
According to Wikipedia, ‘CCGs are clinically led groups that include all the GPs in their geographical area. The aim of this is to give GPs and other clinicians the power to influence commissioning decisions for their patients’. But are CCGs really clinically led?
The number of management directors varies according to the size of the CCG. Most (over three quarters) have a manager as Accountable Officer, and all have a Chief Financial Officer. Larger CCGs may also have a management director for quality, for strategy or commissioning, even for contracting. Where there is a director there is generally a management team, and so the risk is that much of the organisation can start to operate outside of the GPs’ control.
Some CCGs have tackled this by having a ‘Clinical Executive’ or some such group that is responsible for all of the day to day operational decisions of the CCG. This group is ‘advised by’ the accountable officer and CFO. Whether in reality this group is able to take all of the required decisions probably depends on the size of the CCG – this model may work in a small CCG but would be hard to manage in a larger organisation.
Other CCGs have clinical directors who are responsible for specific clinical areas, such as planned care, frail elderly, or mental health. This is an obvious route initially to go down, but in practice it does not answer the question of how the corporate areas of quality, contracting and finance are clinically led.
While you can argue that it is not in a GP’s skill set or knowledge base to be an expert on safeguarding or finance, if a CCG is to be genuinely clinically led then it is important that safeguarding or finance decisions are not taken in isolation of the GPs.
An important question is whether the GPs on the CCG board are GP chairs – i.e. representing a specific group of practices or a locality – or are Clinical Directors. The distinction is important. A Clinical Director carries corporate responsibility for the organisation as a whole, including how areas such as finance and contracting operate. They are not there as elected representatives making sure there interests are reflected.
To some this may seem like semantics, but in order for CCGs to be truly clinically led this is what is required of the GP leaders. It is not just clinicians making sure that the changes to urgent care are clinically led, it is making sure the organisation as a whole is clinically led
All of this of course sits within the reality of the limits on the time of the GP leaders. Often they are carrying out these roles in two or three sessions a week. To really lead an organisation in that time can feel almost impossible.
Some CCGs are recognising this as an issue, and are pairing management directors with clinical directors. The pairing is then responsible to the rest of the organisation for that area, so for example contracting is both the management director for contracting and a specific GP director’s responsibility. It is a version of what hospitals have done with directorates for many years (although not at board level), and is something that may well be effective for CCGs.
There are no simple solutions to ensuring that CCGs are genuinely clinically led. It is, however, critical that they are. What is important is that CCGs continually reflect on how they are developing, how the clinical voice provides leadership, and make changes where they are required.