Archive for May, 2013


So the Secretary of State for Health has decided to ‘take on’ the GPs.  He has claimed that poor GP practices who are offering an inferior service are driving patients to A&E, and that it is down to GPs that they no longer offer a 24 hour service.  He has announced a new Chief Inspector of general practice to crack down on poor performers.  And he has claimed that some GPs do not even know their patients’ names.

GPs are held in a high regard by the general public, and it is unusual for a Secretary of State to go down this route.  It is difficult to understand what outcome he is hoping to achieve, beyond some short term deflection of blame in relation to the problems with urgent care.

This comes on top of increased regulation, driven in the main by registration with the Care Quality Commission.  This will only get worse.  The ombudsman’s decision to ‘usually investigate’ from now on if a complaint passes some simple tests means the number of investigations will rise ten-fold.

We have discussed a number of times on this site that general practice has to provide the solution.  Only general practice can drive down demand to secondary care, and create a system that will be affordable into the future.  It is general practice that is now entrusted, through CCGs, to make this change happen.

So why would Jeremy Hunt try to portray general practice as the problem?  The profession is already under significant pressure.  There is a very real recruitment crisis already in place.  GPs are retiring younger.  A recent BMA survey revealed that 25% of GPs are considering earlier retirement because of the government’s pension proposals, and 43% are looking to stop earlier than they intended 5 years ago.  GPs are leaving the profession on a weekly basis.

The pipeline in is also weak.  The GPC has reported that general practice is in the bottom three of choices young doctors are making in the list of specialties for their careers.  The vacancies that are arising often cannot be filled.  There are now pages and pages of GP vacancies in the trade magazines.  A Pulse survey reported in January that the vacancy rate had risen from 2.1% in January 2011 to 7.9% this year.

Jeremy Hunt’s comments are making this very real crisis worse.  The vacancy rate is rising at an alarming rate and is certainly higher now than the reported figure in January.  Even raising the prospect that out of hours might be imposed back on GPs is enough to make more run for the doors. 

A high vacancy rate in general practice spells very bad news indeed.  Primary care access will suffer (it already is, especially since the access DES was removed), which in turn does affect demand for urgent care across the system.  The ability for general practice to take on any additional services is removed, and the time to input meaningfully into CCGs is reduced (there are already reports of practices having to withdraw from CCG activity because of lack of capacity).

Something needs to change.  Laurence Buckman, in his speech on the 23rd May, concluded,

If society wants GPs available round the clock for routine matters, they will have to understand that daytime access will diminish or there will need to be a greatly expanded GP workforce.  Is the profession ready to deliver what society appears to demand?  If not, what can we offer? GPs will have to wise up or shrivel.  We may have to work in bigger partnerships or federate through some kind of franchise system as some GPs have done.  I think that economic pressure is going to make this happen and we would be wiser to lead the wave rather than follow it.

He is right.  It is already clear that the Area Teams of NHS England, the contractors of primary care, are not capable of leading any sort of change in primary care.  But change is needed.  Only GPs really understand the change that is required, and it is up to general practice itself to make these changes.  CCGs are membership organisations of practices, and as such they are perfectly placed to be used by the profession to enable them to make the changes they need.

Jeremy Hunt will only have a short involvement with health.  He will move on and we will be left with the pieces.  We need to get on with making change happen now, before things get any worse.



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.


Primary care is stuck in the midst of a vicious cycle of declining profits and increasing workload, which makes finding the headroom to change nearly impossible. CCGs are stuck needing primary care to take on more work so that they can reduce the expenditure on hospital care.

We need to break this cycle, to enable both CCGs and primary care to be successful.  The key may lie in out of hours care.

CCGs are responsible for commissioning out of hours care.   PCTs in many places had run out of hours services into the ground.  Using fee for service models, costs had been reduced to the lowest possible point, often forcing local cooperatives who were providing a good service out of business, and bringing in outside companies who struggled to engage local GPs.  Now in many places we have a poor quality service, that struggles to fill its rotas, and that does not play any sort of active part in the local health economy.

Urgent care as we know is struggling across the country.  It is critical that out of hours primary care services plays a full part in managing demand and enabling the system to cope.  At present it is not, and it is clear that a new model is required.

The response of Jeremy Hunt appears to be to blame GPs for agreeing to a contract proposed to them by the government, and to try and pressure GPs into taking out of hours back on.  This, I would suggest, is not the level of thinking that is required.  Many GPs, having tasted life without out of hours, are firmly committed to never taking it back.

The opportunity lies in the fact that many practices understand the need to change as businesses but cannot understand how to.  Taking on new services appears to offer a very limited return and stretches further already over stretched GPs.  The bureaucracy of accreditation for new services creates barriers to entry that are not worth striving to overcome.  How then do practices secure new income streams for the future?

Out of hours is a service that GPs understand, that they have experience of operating at scale, and within which lies the potential for real innovation that will only come from frontline GPs.  Whilst not every GP would commit to out of hours working, if you take a big enough group of practices, rotas will be able to be filled.

The key is innovation.  Two things need to happen.  First, GPs need as a collective to form partnerships with others in the health economy.  If practices can learn to partner effectively as a group with ambulance services, accident and emergency departments, and even 111 (this may be pushing it too far!), out of hours admissions and A&E attendances could be dramatically reduced.

Second GP practices, both as clinical commissioners and as primary care providers, need to move away from fee for service models and embrace fee for outcomes models. CCGs are paying a huge amount for A&E attendances and emergency admissions out of hours.  If gain share arrangements can be developed where savings that are achieved are shared between commissioners and providers, everyone can win.

The existing model of out of hours provision is not fit for purpose.  We need a totally new model.  Primary care, either as commissioner or provider, cannot operate in isolation and be effective.  Out of hours presents a fantastic opportunity for CCGs to demonstrate the impact they can have as commissioners.  It presents a fantastic opportunity for GP practices to start to change the way they operate as businesses.  But time is short.  The urgent care system is in crisis.  CCGs won’t be around for long if they do not make an impact.  Change needs to happen now.


Norman Lamb, the care services minister told the HSJ this week that the Department of Health is considering the future use of the 2%  of CCGs’ budgets which we are required to ring-fence from routine spending.  His proposal is that this should be used to fund integration with council run social care services.

The principle behind the 2% is that this funding is needed to enable the system to drive transformational change.  This is needed if we are to have any chance of dealing with the pressures of the next 5-10 years.  Whilst there is a compelling logic to this, it also requires a reality check.

Clinical Commissioning Groups (CCGs) are at present coming to terms with the reality of the inheritance that the historic NHS system has bequeathed to them.  It is not the balanced budget that was promised when the White Paper was first produced.

Many PCT finance directors managed their budgets by putting as little as possible into the acute commissioning lines, to put as much pressure as possible within the organisation onto that part of the system which represented the biggest financial risk, and then balanced the books by using reserves and underspends from elsewhere at the end of the year.  Allocations to CCGs were based on PCT budgets not historic expenditure, and as such many CCGs are now discovering that their allocation brings with it a significant underlying deficit.

Other CCGs are being asked to bail out the specialist commissioners, who equally feel that insufficient funding has been passed to them.  Some CCGs are even being directly pressured by their Area Teams to take a share of the primary care QIPP requirement.  And all CCGs at some point will be receiving a legacy debt of continuing healthcare claims, which they need to account for.

So the first question is to ask, regardless of the official line of each CCG with the Commissioning Board, is whether the 2% really exists at all.  Do CCGs have any non-recurrent money available for in year investment?  Doubtless some will, but for many it is highly unlikely that the full 2% will be available, and for some there will not be any.

What we have is yet another classic example of policy makers being so distant from the realities of the front line that they create policies based on what they hope is happening rather than what is actually happening.  Promising a non-existent 2% to the council will create such tension in many places that it will decimate not accelerate any prospect of integration.

Attitudes to the 2% vary across the country.  This is a further legacy of the historic system.  In some areas providers view the creation of the 2% transformational fund as a top slice on their budgets, and as such believe they are entitled to their ‘fair share’ of the money.  This has already created real problems for some CCGs in contract negotiations where trusts have been pressing for assurances of additional in year money from the 2%, which as we have seen probably does not even exist.

So how are CCGs who have managed to budget for a non-recurrent transformational fund going to use it?  The big discussion is the extent to which CCGs will use it to accelerate the transformation of primary care.  We have discussed on this site the critical importance of this for CCGs (see ‘What should a CCG Primary Care Strategy look like?’ here).

Some CCGs are shying away from this because of the pressure they are receiving about the 2% from acute providers.  Some are shying away from it because they are worried about the perception that they will be using it to line their own pockets.  But the braver and more progressive CCGs are standing up for what they believe in, that the system needs to change and that change needs to start with primary care, and are putting their money where their mouth is.

Bold decisions are needed by CCGs to break the cycle of ever increasing expenditure on acutes, and to make care closer to home a reality.  CCGs need to be left to drive change locally, and to drive integration locally, without being hamstrung by policy makers making decisions with no basis in reality.