Archive for October, 2012


You may or may not have heard of Epanutin.  It is a drug that was previously marketed and distributed by Pfizer and, since the 24 September, is being marketed and distributed by Flynn Pharma.  There is no difference in the way the capsules are being manufactured.  The only changes are to the name, and to the price.  The increase in price is a jaw dropping 24 fold increase.  The cost pressure to the NHS is likely to be £50M per again.  It provides no additional health benefits for patients.

So how should CCGs respond?  The usual work arounds are not available: there are no cheap generic alternatives, and no parallel imports.   Do we just take it lying down, and accept that it is the world we are operating in, and that these things are just going to happen?

I would suggest we do not just accept this.  It could well be that the pharma companies in these economically distressed times, seeing the general disarray caused by the reforms, are simply chancing their arm to see what they can get away with.  If this is the case it is very important that Clinical Commissioning Groups (CCGs) are seen to be strong collectively as well as individually, and that they are not providing an environment that allows the NHS to be taken advantage of.

There has been some press interest in this, see for example:

The (minimal) public reaction to this interesting: an automatic assumption of blame to the NHS for allowing it to happen rather than to the pharma companies for concocting it.  The pharma companies simply hold a line that the new price is a more accurate representation of the true costs.  Pfizer still manufacture the product, but in this arrangement can allow the much smaller Flynn Pharma to take the reputational hit for the price hike.CCGs do not have now, and will not have in the future, £50M per year to fund price hikes like this.

I know a number of CCGs are now writing to their MPs, their local papers and whoever they know who has influence.  If all of us do what we can and can somehow get this changed, we will not only be doing a service for  the NHS as a whole, we will be sending a clear message to those watching about the consequences of these types of decisions, and maybe prevent some of them happening in future.


The success of Clinical Commissioning Groups (CCGs) is dependent on their ability to transform primary care. Whilst this statement is in danger of becoming a cliché, it is true.  This is because a key requirement of CCG success is the ability to move activity out of the acute hospital setting.  If the shift is from acute to community it is likely to have a minimal impact on cost, demand will probably rise, and quality will almost certainly fall.  The shift needs to be directly into primary care so that it is linked to the core gatekeeper role of general practice.

But for this shift to take place primary care needs to change.  Currently most practices will blanch at the prospect of more work.  Primary care is full, and has no capacity for additional activity.  More worryingly, most practices lack the capacity or capability to expand to be able to take on more activity.  CCGs are left with the conundrum of wanting to invest in primary care, but primary care seemingly not able to accept the investment.  Practices are seeing workload go up, but drawings go down.

For primary care the situation is only likely to get worse.  Local enhanced services are being split between CCGs, the NHSCB and public health, and many may be offered to other providers.  The NHSCB will undoubtedly try and bring standardisation to the way the core contract is implemented.  Notional rent looks certain to be time limited, and access to capital is highly likely to be down to individual practices as the days of NHS handouts to practices are coming to an end.

So what do CCGs do? How do they create a primary care strategy that is meaningful to practices in this environment?  A good place to start is to look at the ‘Super Partnerships’ model that Helen Parker and others are implementing in Birmingham (  They are building bigger practices (50-80,000) which have a lower dependence upon the core GP contract (40% and more of the income comes from non-core contract work).  They are not using all the revenue as drawings, and instead are investing in the business to continually build capacity and capability to take on more work.  Super partnerships are not the only answer.  But they point the way, and start to create a picture of what the future of primary care could look like.

CCGs, or more specifically localities within CCGs, are ideal mechanisms that primary care can use to change themselves.  If the member practices in a CCG understand what is required of primary care through the CCG core business, and can use the strengthening of inter-practice relationships that CCGs bring, there is an opportunity for practices to start to work together to reshape their own businesses.  The challenge for a CCG is to create a primary care strategy that maps directly to the business strategy of each individual member practice.

Most practices will turn up at CCG or locality meetings and pay lip service to the work that is going on, but the real day job lies back at the practice.  The content of the locality meeting has a tangential relevance at best.  The ambition of a CCG primary care strategy should be to ensure it is totally aligned with the core business strategy of each of its practices.  If the two can work together then primary care can rescue their businesses, and CCGs can be successful.

PCT primary care strategies were always top down creations that had little relevance to individual practices (beyond the resentment they generated with the introduction of the dreaded balanced scorecard).  CCG primary care strategies, if CCGs can succeed in making them relevant and owned by their member practices, have the potential to truly transform primary care.



In any Clinical Commissioning Group (CCG) that has a locality structure, there will be variation in performance between the localities.  The challenge for CCGs, who have committed to a devolved model of delivery through localities, is how to tackle this variation, particularly how to tackle those localities that are not delivering to the same extent as the others.

The bigger the CCG, the more important the locality structure is.  It is the system that allows the CCG to operate as a true membership organisation, and that builds upon engagement in each individual practice.  Determining how to tackle poor performance at locality level starts with an understanding of what drives strong performance.

High performing localities have characteristics that are way beyond QIPP performance.  They have a way of engaging each of the constituent practices so that they become active members.  The representation from each practice is appropriate, senior and acts as a genuine conduit between the practice and the locality.  Trust and a sense of shared purpose between the practices is in place.  Locality meetings feel more like a team meeting than a battleground. 

The practices have a high level of confidence and trust in the GP Chair of the locality.  The locality has a shared picture of what it is trying to achieve.  The locality turns the ideas that the practices have into actions, generally by having a capable management resource.  It has a plan for what it is going to do across the year, which it monitors and reports on both to each practice and to the CCG.

The locality feels like it is part of the CCG, not at war with it.  It feels like its voice is heard and understands the role it plays within the CCG as a whole.  The locality believes in the CCG leadership and the CCG leadership believes in the locality, mainly because there is regular communication between the two.

For those who work with localities, while this picture does not sound wrong, it does feel some distance from the reality!  Localities are often characterised by inaction, divisions between practices or individuals, no clear direction, and an underlying dissatisfaction with the wider CCG.  In this situation there are potentially three levels of intervention a CCG should take:

1. Improve the support the locality receives.  As with anything, the first place to start when looking at any problem is yourself, in this case the CCG.  Localities can only be successful if they are given the right support.  In particular it needs a proper programme of support for the GP Chair.  These are new and difficult roles and adopting a sink or swim approach to success is unlikely to prove the most profitable.  The management resource needs to have the capacity and capability to corral the practices and turn the ideas into actions.  Localities cannot function effectively without clear and consistent information at locality and at individual practice level.  Clear systems of autonomy need to be in place: the CCG needs to have absolute clarity as to what decisions the locality can take and which need to be approved.   CCG leaders (GP Chair, Accountable Officer etc) need to take responsibility for connecting the locality with the wider CCG and ensure really strong two-way communication is in place. They should not leave this all to the GP Chair, particularly when difficult messages need to be given.

2. Change the leadership of the locality.  Most locality issues can and should be resolved by improving the support the locality, including the leadership of the locality, receives.  But there are localities where those leading the locality are not capable of creating the sense of cohesion and ‘team’ that the locality needs.  Rifts between practices can be deep and long standing and leadership skills beyond those that exist within the ‘willing volunteer’ currently chairing the locality are required.  Or the CCG may need to change the management leadership working alongside the GP Chair, if no real viable alternatives to the GP Chair exist, to ensure the skills that are needed are brought into the locality.

3. Reshape the Locality Structure.  Localities can be designed in a way to prevent them ever being successful, regardless of the leadership.  They can be too large, so that many of the constituent practices do not know each other and have no sense of affinity with each other.  Here the locality construct feels entirely artificial.  There are too many practice representatives for there to be any chance of creating a cohesive team.  Individual practices find it difficult to get their voice heard, and lack of attendance by individual practices goes largely unnoticed.  Localities can also be too small, particularly where one dominant voice creates resentment and disengagement with the other practices.  In these instances CCGs need to recognise they are still at an early stage of their development and be brave enough to change the locality structure.

Many from a performance background in PCTs or SHAs are sceptical about the ability of CCGs to deliver through a locality structure.  As the alternative is to revert to a centralised model, it is critical that CCGs take robust measures to tackle under-performance to build confidence in the model, as this sits at the very heart of long term CCG success.