Archive for the ‘GP Practice Engagement’ Category


The biggest criticism GPs level at their CCG faces is that it has ‘become the PCT’.  GP practices have engaged with CCGs on the basis that things will be different, and that the unilateral decision making of the past will not be a feature of the future.

This presents a real challenge for CCGs.  The pressure for action and for quick decisions from the Commissioning Board and from acute trusts and other organisations make it difficult for CCG leaders to be constantly saying that they will check with their practices and get back to you.

The challenge is to get the right balance between the leadership making decisions quickly, and taking time to engage with practices when decisions need to be made.  If a CCG leadership team get this balance wrong, they will quickly find out about it.  Either the member practices will accuse them of acting like the PCT, or partner organisations will claim they are slow and unresponsive.

The larger the CCG the harder this challenge becomes, because it is harder to get the views of so many practices in a short space of time.  This risks practices becoming disenfranchised and the engagement that is so critical to CCG success dissipating.

So what steps can CCGs take to meet this challenge?  The first is to ensure there is high visibility of the leadership team by the practices, in particular the Accountable Officer (and Clinical Chair if the Accountable Officer is a manager).  If practices are confident that the leadership understand where they are coming from they are much happier for decisions to be made on their behalf.  Dissatisfaction arises when decisions are made that are not explained and seem to take no account of what these decisions mean for practices and their patients.

The second step is to ensure that there is an explicit understanding of which decisions need direct practice involvement.  The reality is that it is not possible (or desirable) to involve every practice in every decision.  But this does not mean that they should not be involved in any.  CCGs must have mechanisms for identifying which decisions require all practices to be involved, and then for acting on this.

This is particularly important for the most contentious decisions, which will often be the decisions that directly impact upon primary care.  CCGs need an extremely transparent and fair process that engages practices, but does not just involve GPs, when making decisions that impact upon primary care income.  These include decisions on local enhanced services, on how the quality premium will be used, on any practice incentive scheme, and to a lesser extent on any support linked to delivery of the QOF commissioning indicators.

It is also worth CCGs considering having something akin to a ‘management allowance committee’ that oversees how the £25 per head is used, that creates a transparency with the member practices.  When practices feel that the CCG is using the management allowance in ways they do not understand a divide can quickly develop between the practices and the CCG.

The third step is to ensure that when a decision has been identified that requires input from all practices, that there is a mechanism for making this happen.  This cannot always be that the discussion goes to a set of once a month locality meetings and then be brought back to a further joint meeting.  Whilst sometimes this will be appropriate, taking 6 weeks or more to make a decision is simply too long.  Virtual mechanisms need to be put in place that are effective, that can operate alongside face to face meetings.

The final step is to continually review the processes that the CCG has in place.  Getting the balance right is almost impossible to achieve, so working out whether it is speed of decision making or practice engagement that is suffering will be a quick guide to how things need to change.  For CCGs to be different, and to be clinically led organisations that have genuine practice engagement, they must strive to rise to this challenge.



I met with a CCG Director recently after he had just had his latest difficult meeting with the Area Team of the NHS Commissioning Board.  He was reflecting that the CCG needed to spend less time having cups of coffee ‘engaging’ GPs and more time on actual delivery, and was asking my advice.

Engagement is often seen as soft and an optional extra by performance managers.  Delivery on the other hand is seen as being about tough conversations and telling people what they should be doing. 

This presents an interesting challenge for Clinical Commissioning Groups (CCGs) as membership organisations.  Should CCG leaders be having tough performance conversations with member practices, or should they be spending time engaging practices with the work the CCG is doing?  Has the time come to stop trying to persuade GP practices of the need to be engaged, and to start taking a more directive approach?

It is worth clarifying exactly what we mean by delivery.  CCGs need GPs to ‘deliver’ in a range of different ways.  There is controlling referrals, often by agreeing to some form of practice-wide review of all referrals.  There is controlling prescribing costs by ensuring that cost-effective medicines are being prescribed.  There is the use of referral criteria for certain conditions and procedures, particularly where they fall into the ‘right care’ category.  This can involve telling patients that the pain in their knee or hip is not yet bad enough for them to warrant the risks of a surgical procedure.  It also means participating in the various schemes that the CCG has running, such as daily rounds of all the patients in the local care home, or working with the local school nurse to avoid children being sent to A&E.

This work is not contractual.  GPs are taking this on because they are part of the CCG.  There may be local incentive schemes in place, but rarely will these cover the costs of the time involved.  Plus they are generally paid on results rather than inputs, which is never attractive for GPs.  Equally, for CCGs to be successful, participation in this work cannot be like a local enhanced service (LES) where each practice makes an individual decision as to whether the reward is worth the effort involved.  The CCG needs every practice to fully participate.

CCGs have very limited contractual control over their member practices.  Recent history, and any sensible review of PCTs, demonstrates that using contractual controls to drive GP practice delivery does not work.  The very notion of a distant organisation telling practices what they have to do is a fast track to CCGs picking up the criticism that they are ‘just like the PCT’.

The strength of CCGs lies in their ability to drive delivery through engagement in a common goal across member practices.  It lies in the sense of ownership that practices have of the organisation as a whole.  It comes from a shared belief that by working together the practices can make a difference.  It comes from each individual practice feeling that they are part of something bigger.  It comes from being engaged.

Practices do not deliver because the CCG tells them to.  They deliver, and go above and beyond what could reasonably be expected of them, because they are partners with their fellow practices in the CCG.  They do it because they believe that by working together they can make a real difference for patients, not because a distant organisation has told them to.  Ultimately delivery comes because practices are engaged with the work of the CCG.  If they are not engaged they will not deliver.  Simply telling practices that they have to deliver will not help.

It is not just CCGs.  A Gallup study in 2006 looking at data from 24,000 businesses has demonstrated that engagement and delivery are directly correlated: those with the highest engagement scores (top 25%) averaged 18% higher productivity than those with the lowest engagement scores (bottom 25%). 

When CCGs are struggling with delivery it is really important they do not revert to the old behaviours of highly directive performance management.  My response to my colleague was that he should keep faith with what he was doing, and that whatever the views of those in senior roles in the NHS Commissioning Board may be, to be clear that it is engagement that will drive delivery.  He decided to leave the big stick in the PCT drawer and keep going with the coffee.


The most common criticism that practices have of their CCG is that it is becoming ‘just like the PCT’.  This is born out of a sense of decision making being distant from practices, from decisions being taken that are unpopular and not understood by practices, and, frankly, by a sense that the bottom line is being put above patient care.

Commissioning in the new world is not going to be easy, whoever does it.  For Clinical Commissioning Groups (CCGs) there will be the need to make tough decisions, where whatever is decided there will be those who are unhappy.  The key difference, however, between PCTs of the past and the CCGs of the future is the establishment of ‘localities’.

Most CCGs have a locality structure of some description.  A locality is a grouping of practices within a CCG.  They are generally (but not always) developed based on geography.  They vary in size, but the prevailing wisdom is that the optimum size for a locality is a population of 50-100,000, and a membership of 5 – 10 practices.  Localities that are too large or contain too many practices become impersonal and mutual accountability becomes harder.  For more on making localities effective see the article ‘How to tackle underperforming localities’ here.

Success for a CCG ultimately will depend on its ability to influence on the one hand its main providers and on the other its member practices.  The locality structure is important because it will ultimately define the relationship a CCG has with its practices.  This in turn will determine the level of influence the CCG has with its practices.  But the existence of a locality structure masks fundamental differences between CCGs in the way that they operate.

CCGs have approached the development of localities in two fundamentally different ways.  There are those CCGs where the majority of decision making, plan development and innovation take place centrally.  The localities are used as mechanism for ensuring effective communication of CCG decision making takes place with practices, and for implementation of those actions that require individual practice action (e.g. reduction of referrals).  For these CCGs the majority (if not all) of the resource is coordinated centrally.

However, other CCGs have devolved more of the resource to the localities.  In this model planning is owned by the localities and coordinated centrally.  Accountability sits primarily with each locality rather than the ‘central’ CCG, and works with the localities being accountable to each other for delivery.

This second model is much harder to put into practice.  For a start it has not been done before, so there is no easy roadmap to making it successful.  There are many pitfalls that CCGs pursuing this route are coming up against, such as working out how to balance the distribution of resource locally and centrally, and putting effective systems of control in place that enable statutory responsibilities to be delivered within a devolved structure.  But if done well it creates real practice ownership of the CCG in a way that the first model will struggle to achieve.

The authorisation process will not have been influenced by which of the two models a CCG has chosen.  But this choice may ultimately have more influence over which CCGs will be successful in the long term.  The relationship between the CCG, with all its statutory responsibilities, and its member practices, with all the pressures they face, will be a critical success factor for the long term success of CCGs.  Localities are the key to making that productive.  Without effective localities CCGs will become a less effective version of PCTs, but with them they have the power to transform health systems.


“A new world order is taking shape so fast that governments as well as private citizens find it difficult just to absorb the gallop of events” Mikhail Gorbachev, 1990

When in the midst of transition, it is easy to get lost in the detail, and forget the size of the overall change that is taking place.  The introduction of clinical commissioning groups (CCGs) is only one part of the transformation that is taking place in the NHS, but it is of itself a momentous shift.

What was effective in the old world is not necessarily what will be effective in the new world.  CCGs require a different style from that which preceded them.  I want to share a personal example to illustrate this very point.

We recently developed a new 3 year strategy for the CCG.  We had worked intensively with support from management consultants over a number of weeks to develop clear strategic objectives, supported by a series of transformation programmes.  This was all underpinned by a robust set of financial projections outlining a clear bridge analysis between the ‘do nothing’ scenario and long term financial health.

The strategy was presented to two audiences.  The first audience was a mixed group of lay members, patient representatives, senior managers, and lead GPs.  It was extremely well received.  The group liked the ambition of the objectives, the financial robustness of the strategy, and the clear framework provided by the transformation programmes that was neither too vague nor too prescriptive.  The whole strategy was visually summarised in a single slide that all applauded.

So far so good.  The second audience was a group of GP leaders and member practice representatives.  They hated the strategy.  While there was some sympathy for the overall health improvement objectives, they hated the style and layout of the document, they hated the length and prescription of much of the work, and they hated the financial bridge diagrams that the first group had particularly praised.

In discussion the reasons for this became clear.  The document looked and felt too much like the PCT documents that had preceded it.  It was not the quality or otherwise of the content that was the problem.  It was the distillation of the work of the next three years into a slide set.  It was the impression that the world is controllable and that all it needs is the right plan.  It was the lack of resonance between that which was presented and the world in which the member GPs operate on a daily basis.

There is a new world order.  What worked in the past, what set some PCTs apart as ‘world class’, will not work in the future.  CCG leaders need to find new ways of communicating that resonate with member practices.  As we have discussed many times on this site, the critical success factor for all CCGs is active engagement at the level of each member GP.  It is no good a CCG having the greatest strategy in the country if its member practices do not recognise or own it.

We agreed to work with volunteers from the second group to develop a new version of the strategy, one that is fit for the new world.  CCGs will need to find a way of enabling their leaders to be effective in this new world.  For many new CCG leaders it will be a totally alien environment.  CCGs may have gone to great lengths to recruit (for example) the best possible Chief Finance Officer, but without real support from the GP leaders in how to operate in the new world they will struggle to be effective.

The reality is there is no magic formula for operating in the new world.  I have no idea what our strategy will end up looking like.  All I can do is learn from the mistake, keep talking to the member practices, and make sure that as an organisation we prioritise GP engagement over everything else.



As the spectre of the 360 degree assessment looms large for all prospective CCGs, it is interesting that it is the returns from member practices that many CCGs are concerned about.  Many GPs are unhappy with CCGs in general, exacerbated by the back door nationalisation of the profession that mandatory membership of a CCG brings.  The worry is that practices will use the survey as an opportunity to vent their frustration.

Engagement of front line, grass roots GPs is the critical success factor for CCGs. The importance of employee engagement as a requirement for organisational success is well recognised.  Jack Welch, former CEO of GE, puts it well, “There are only three measurements that tell you nearly everything you need to know about your organisation’s overall performance: employee engagement, customer satisfaction, and cash flow…It goes without saying that no company, small or large, can win over the long run without energised employees who believe in the mission and understand how to achieve it…”.

GPs are members of CCGs not employees. Fair enough. But the need for real engagement as a member is no less than that required by employees in most businesses.  Ultimately CCGs require a transformation of primary care if they are going to be truly successful. They need a step change in activity taking place in primary care, that stays linked to the ever developing gatekeeper role, which as finances tighten becomes the critical CCG lever.

So what does an engaged GP look like?  A good description comes from ‘Closing the Engagement Gap’ by Don Lowman and Julie Gebauer, “…an engaged (GP) understands what to do to help her company succeed, she feels emotionally connected to the organisation and its leaders, and she is willing to put that knowledge and emotion into action to improve performance, her own and the organisation’s.”

For many CCG leaders right now, this feels many worlds away. Others are on a journey where there are small numbers in this place, but not enough. So how do we get there?  Ultimately this is a function of leadership and relationships, that spread through the organisations.  It starts with the overall GP lead, who works to create an engaged set of GP leaders.  These leaders then work with their group of practices, trying to create an engaged set of leaders, one from each practice.  These practice leaders then go back to their practices to develop engagement from each of the GPs.

So simple in theory, but of course reality is a different matter.  There are, however, steps CCGs can take to make this Utopia more of a reality:

1. The most straightforward step a CCG can take is to ensure that each CCG GP leader is providing leadership to a small number of practices.  Ideally this will be between 5 and 8, and an absolute maximum of 10. Engagement requires real relationships and creating a sense of team, which is very difficult to do when the number of people is too large.

2. If a group of practices are not ‘delivering’ (whatever that means!), the CCG response must focus first on engagement and not on performance management.  No real change is possible without hearts and minds, and so ‘getting tough’ with practices at the first sign of performance issues is potentially the single biggest mistake a CCG can make.  The GP leaders need to be supported to develop effective engagement with their practices, not to deliver performance management.

3. The management textbooks will tell you that the single most important element to engagement is communication.  CCGs must find ways of regular, effective communication with practices.  There is no one right way.  There just needs to be lots of ways, all regularly reviewed, developed and improved.  The biggest complaint GPs had with PCTs is that they never communicated with them, so this needs to be huge priority for CCGs.  Interestingly, GPs tend not to like overly glossy communication.  It needs to be simple, straightforward, honest and jargon-free.

4. The GP Chair/accountable officer must have a regular presence in local meetings.  A telling story came from one CCG where the GP Chair asked the practices what he needed to do to make sure they succeeded where the practices felt the PCT had failed.  ‘Come to our meetings, and speak to us face to face’, was the response.  Practice leaders value very highly the ability to directly interface with the top of the organisation.

5. Delivering some real improvements is of course critical to demonstrating that clinical commissioning can make a real difference.  The lesson we can learn from practice based commissioning is that delivering the change in itself is not enough.  The change needs to be communicated over and over again.  GPs will sometimes even see that a change has taken place, but have no idea that it was down to the efforts of a CCG.  Changes need to be made, and the benefits need to be claimed.  Once there are demonstrable improvements for patients, when good ideas have been actioned instead of ignored, and the benefits are being palpably felt by GPs, that is when there is a platform for engagement.

6. The drive for engagement in commissioning needs to be cogniscent of what life is like for GPs at present.”But I like to think that a lot of managers and executives trying to solve problems miss the forest for the trees by forgetting to look at their people — not at how much more they can get from their people or how they can more effectively manage their people. I think they need to look a little more closely at what it’s like for their people to come to work there every day.”  Gordon Bethune, Continental Airlines.

GP practices are full.  They are not overloaded with spare capacity to attend commissioning meetings, or to introduce the latest scheme.  CCGs  need to acknowledge this openly and regularly if they are to progress real engagement.

7. Use financial incentives.  They have a proven track record in primary care.  They are relatively blunt, and CCGs want to avoid a ‘fee for service’ relationship with practices, but the upside far outweighs the downside, and they are a great way of genuinely acknowledging the pressure GP practices are under.

8. Regularly report on engagement at the Governing Body meetings.  Practice engagement needs to be reviewed alongside all the financial, quality and performance metrics.  It is notoriously hard to measure, but simple proxies are not hard to create.  These can start with attendance at commissioning meetings and move into regular engagement survey scores.  It probably will not be very long before CCGs start using the net promoter scores with their own practice (‘would you recommend your CCG to another practice?’).

Engagement of GPs is elusive and it is slippery.  It is something that Clinical Commissioning Groups (CCGs) work hard to find and then, once they think they have it, they turn round and it is gone again.  The results of the 360 degree survey will be interesting, but they will only ever represent a point in time, and all CCGs will need to continue to prioritise GP engagement in order to be successful.

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Potentially the biggest challenge facing CCGs today is delivery of the 2012/13 savings (or QIPP) plan.  As the spectre of authorisation grows, it would be a brave CCG that entered the process as it was falling significantly behind on its delivery plan.  Good CCGs will have broken the plan down to practice level so that it is clear what each practice is required to deliver, in order that the CCG as a whole can deliver its plan.  This is the core strength of CCGs: that they are able to develop plans that are owned, supported and driven by their member practices.

But many practices are not as signed up to the whole commissioning agenda as some of their more enthusiastic leaders.  They have felt the extra workload that comes with being in the CCG, such as reviewing partners’ referrals before they are sent, following rafts of new protocols, and receiving calls from ambulances and A&E when their patients have accessed the service ‘inappropriately’.  The prospect of carrying out even more work ‘for the good of the CCG’ in many places is starting to grate, and the ‘what is in it for me’ question is coming to the fore.

Enter the question of incentivisation: should CCGs be incentivising their practices to deliver their share of the commissioning agenda?  Or is this now part of core general practice, and should more focus be on developing a system of penalties for those not pulling their weight?  Is it even ethical for CCGs to pay practices for delivery?  Isn’t there something morally wrong about paying practices ‘not to refer’?

This is a difficult question (note the resounding silence on the once heralded quality premium).  But it is a fundamental issue, because at its heart lies grass root GP engagement with CCGs.  If these GPs disengage (and engagement is not a once won forever held commodity, it can slip through your fingers at any point) then commissioning reverts to the preserve of the few and loses the power it has from the many.

A helpful starting point is to consider why a CCG might incentivise its practices.  The fundamental strategy of most CCGs is to shift activity, workload and resources out of hospitals and into community and primary care.  But if you speak to most GP practices they are already struggling with capacity. They can see no mechanism which will create the resource required for them to take on this new work.  CCGs, despite the much-heralded conflict of interest, do need to invest in primary care.  They do need to find a way to create the capacity that will enable them to fulfil their ambition to shift resources out of hospitals.

This investment needs to be significant.  LES’s that generate £5000 a year do not create enough funding for a practice to take on new staff or build capacity.  There also needs to be a degree of certainty attached to it.  If delivery is outside of the practice control it will not lead to the investment in capacity that is required.

CCG incentivisation of delivery of plans at practice level is a mechanism for investing in the capacity required in primary care to create the radical shifts in activity that will ultimately determine the success (or otherwise) of CCGs.  As member organisations CCGs need to find ways of driving and maintaining the engagement of every member of every practice.  They need to create compelling pictures about future models of primary care, and a clear route map as to how these are going to be achieved.  Delivery of this year’s plan needs to be the first step along this journey.  Payments for delivery are not payments to line the back pockets of member GPs.  They are returns for the investments required for practices to be able achieve delivery in the first place.

So create a LES.  Make it significant.  Put the majority of payment based on delivery at practice level.  Make it significant enough so that practices will invest to ensure they achieve.  Create metrics in the LES so that as a CCG you know that it will only be delivered by actions taken at practice level.  Do not structure payments so that they stifle innovation – base them on delivery of outcomes, not on following processes.  Do not worry about the practices that do not deliver – if you are paying a percentage of delivery, non-delivery costs nothing.  Understand that the payment itself is an investment in primary care to accelerate delivery of the future.  And trust that the engagement this will drive at individual GP level is priceless.



As the number of Clinical Commissioning Groups (CCGs) shrinks and the average size gets higher, more and more smaller groups are ‘federating’ together into a larger organisation.  Here we explore what lessons CCGs can learn from one of the most successful examples of a federation being formed (the six colonies coming together to form a single Australia), and from one of the least successful examples (the brief establishment of a West Indies federation).

So why did Australia succeed where the West Indies failed?  A key reason was that the six colonies of Australia (Western Australia, South Australia, New South Wales, Victoria, Queensland and Tasmania) identified with the overall continent of Australia, and understood that there was a logic to them forming a federation.  The need to work together to protect the vast empty area of Australia was clear.  It is interesting that New Zealand chose not to join, for the very reason that they saw themselves as a different country, with a different climate and separated by the sea.  They did not naturally identify with the proposed federation. It is also worth noting that while the federation is considered to be of substantial importance to many Australians today, in 1901 when the federation was formed many of the general public were apathetic to it, and more concerned with dealing with the effects of the depression of the 1890s.

The West Indies federation was created in 1958 by Great Britain to enable it to become a fully independent state.  It was set up between 24 inhabited islands in the Caribbean, but there was no popular support for it.  Lack of identification with the federation by both the people and their leaders was one of the key problems that the West Indies faced.  People identified with the island they lived on, not the wider federation, and by 1962 the federation had been dissolved.

So the first lesson for CCGs is that the federation must make sense to the members.  There must be a logic to it and some natural sense of community amongst those who are involved.  Artificial constructs are much more likely to fail.  CCGs that widen across county boundaries where no historic links have existed could well be storing up problems for the future.

The Australians identified some clear benefits to federation.  Both Australia and the West Indies were seeking independence from England (there may be some parallels between colonial Britain and the NHS Commissioning Board!).  The Australians were keen to keep out unwanted foreigners, and needed a collective approach to dealing with the unions that were operating across the colonies.  There were also tariffs on the transport of goods across borders and the federation provided the opportunity to improve trade across colony boundaries.

What Australia succeeded in doing that the West Indies did not was driving the delivery of the potential benefits.  The West Indies never achieved a single customs union or freedom of movement.  The Australian colonies felt that if they fell on hard times that the others would come to their aid.  The West Indian island states did not share such a belief.  In the end the Jamaicans felt that achieving independence from England would be faster on their own than as part of the federation, and the federation collapsed.

There are some clear benefits to smaller groups federating together into a larger CCG.  There is buying power with commissioning support services, or the ability to deliver all support services directly.  The management allowance goes much further with statutory overheads only needing to be provided once.  A larger group can have much larger and more powerful voice with external stakeholders, including the NHS Commissioning Board, the Health and Wellbeing Board, and acute trusts. And potentially most importantly the financial position is much less volatile and can be kept much more within the CCGs control for a larger federated group.

But these are only potential benefits. They do not come simply because the group is larger.  The CCG has to work hard to deliver and maximise the benefits.  At the same time it needs to communicate these benefits to the member practices, because as in the case of both Australia and the West Indies they are likely to be apathetic at best to the federation.  Failure to do this will lead to individual groups within the federation thinking they can do better on their own, and the likelihood of the federation breaking up becomes much more real.

Australia had some strong leaders such as Alfred Deakin driving the federation.  They influenced the press where they could to provide a strong, consistent, reinforcing message.  The West Indies were plagued by political feuds between the influential leaders.  The office of the prime minister was weak, so strong central leadership never prevailed.

Strong leadership is needed in all CCGs, but particularly in large CCGs.  The Chair, Accountable Officer and whole Governing Body need to provide strong collective leadership, drive the federation, articulate the benefits of federation consistently and continually, and work together to resolve issues and disputes as they arise in a clear and transparent way.  Federations are fragile, particularly in the early days, and need to be respected and treated with care.  The key message from Australia in 1901 and the West Indies in 1958 is understanding that forming the federation is the point at which the real work begins.

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The DH document ‘Baseline Spending Estimates for the new NHS and Public Health Commissioning Architecture’ singlehandedly has the power to derail the progress made by CCGs to date.  The document can be found here:

The key point of this document is that CCG allocations are based on 2010/11 expenditure.  While the rationale for this is clear (i.e. that introducing variation in funding by moving to a capitation based allowance would have a highly destabilising impact on providers), this rationale is now new.  It is no truer today than it was last year, when Barbara Hakin clearly stated that CCG budgets would be based on some form of weighted capitation formula.

So what is the big deal?  The issue is that any CCG worth its salt has been trying to create GP ownership of budgets.  Over the course of this year GP practices, localities and CCGs have been developing a growing understanding of their budgets, and generated plans to bring these under control.  Aspirant CCGs have built on the progress made through practice based commissioning to move to ‘fair share’ budgets.  Using all the indications from the centre, plans for next year have been based on capitation based budgets.  Now, less than 2 months before the start of the financial year, when CCGs should be nearing the completion of their financial plans, this process have been thrown into disarray.  CCGs and localities that thought they have significant gaps find they do not, and those that thought their budget was under control suddenly face a huge challenge.

The heart of the move to GP commissioning, that was always the failure of practice based commissioning, is GP ownership of and accountability for their budget.  It is impossible for CCGs to develop effective systems of accountability for GP management of their budgets, when the goalposts keep shifting.  GPs can rightly ask how they are expected to manage a budget that keeps moving so significantly year on year.  GPs can also rightly ask why they are expected to manage a budget that is not ‘fair’, i.e. one set on the basis of historical patterns of expenditure, rather than based on the needs of the population they serve.

This new DH document makes it twice as hard for CCGs to generate real practice ownership of their budgets, to the point where they genuinely feel accountable for them.  It represents two steps back against the real progress that GP commissioning has made this year.  CCGs need to stand together and fight for fair share budgets, regardless of whether they ‘win’ or ‘lose’ through the allocation process.  Without accountability for budgets  at practice level, the real benefits of CCGs will never be delivered.

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Size matters not. Look at me.  Judge me by my size, do you? Hmm? Hmm? And well you should not.  For my ally is the force, and a powerful ally it is.’ Yoda, Star Wars.

Much has been made of the size of a clinical commissioning group (CCG).  Debate rages as to the elusive ‘right size’ of a CCG.  Proponents of big CCGs argue that the small CCGs cannot function effectively due to the restrictions of the management allowance of £25 per head of population.  Proponents of small CCGs claim large CCGs are PCTs recreated and lack real GP engagement.

My concern is not with very big CCGs or very small CCGs.  My concern is with the reported 163 CCGs (out of 279 – as reported by the Health Services Journal 5/1/12) that are between one and three hundred thousand population.  This is the worst of both worlds.

The ‘force’ of CCGs is the ability to make every GP an active commissioner.  This might mean adhering to agreed pathways or agreeing to have their referral reviewed by a peer before they are sent.  Alternatively it might mean leading a contract negotiation or reviewing the mortality rates of the local hospital.  The level of involvement can vary, but participation by all is the key to success.

So what is the problem with an average sized CCG?  Well a very small CCG covers a population where all the GPs know each other, share the same concerns, and can hold each other to account.  There is no hiding place because there are only a small number of practices involved.  If one is not participating the others will tackle it.  In a very large CCG the size forces the organisation into ‘localities’ or some similar sub-structure which can allow the same benefits of the very small CCG to be achieved.

But CCGs where the population is 1-300,000 are looking at between 10 and 30 or even 40 practices being involved.  The temptation will be to try and run the group as one big collection of practices.  It is hard for 30 practices to work effectively as a single group together.  The GPs do not all know each other.  The needs and requirements of the population will vary between different practices.  Some practices will rarely contribute.  It is much easier to hide in a group of 30 than a group of 6.

Governing Body meetings may end up with a representative from every practice.  If so they become unwieldy in size and high quality, timely decision making will be difficult.  Alternatively a select few will make decisions on behalf of all, but then it will be difficult for all to feel they have been able to contribute when difficult decisions are made.  If practices do not sign up to a decision that has been made, and do not feel they had chance to influence it, chances are they will not take the necessary steps to implement it.

So what should these CCGs be doing? Well for any population over 100-120,000, or where there are more than 10-15 practices (15 very small practices can probably work effectively together, but 10 large practices is probably the maximum), CCGs should consider introducing a locality structure.  Practices should be grouped together into self managed accountable units as part of the overall CCG structure.

It is not the size of the CCG that matters; it is the ability to harness the force…

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