Summary
This study provides evidence about the attitudes and beliefs of those currently undertaking formal roles within CCGs. Repeated references were made to the value of the clinical knowledge and the knowledge about service provision that GPs bring to the process. In terms of the aspirations of those responsible for implementing CCG policy highlighted in Box 1, the responders clearly shared NHSE’s optimism that clinicians in CCGs will use their clinical knowledge to improve commissioning. They also believed that CCGs have the potential to improve quality in primary care, although this will depend crucially on the ability of CCGs to engage their members. The claim made by NHSE that clinicians will be able to use their position as trusted members of the community to engage with the public, and persuade them of the need for wider-scale system transformation, did not arise in these interviews, and indeed seems to lack face validity. There is no a priori reason as to why CCGs should be better than PCTs at engaging the public with the need to close services, and it is at least plausible that those with detailed knowledge of patients’ wishes are less likely to take the risk of engaging in difficult service reconfigurations.
Comparison with existing literature
The claims made by the responders highlight two aspects of GPs’ knowledge and experience. The first is that their knowledge about services and patient needs is ‘fine-grained’. By this, it is meant that their knowledge is rooted in the experiences of individuals, and that their role as front-line clinicians seeing significant numbers of patients allows them to aggregate that knowledge to provide an overview of the whole system. This claim is interesting, as it carries within it two assumptions: first, that such aggregated knowledge of individuals is sufficiently representative to illuminate the system as a whole; and, secondly, that personalised knowledge such as this is in some way more useful than the more systematic evidence about service quality or efficiency historically gathered by PCT public health staff to support the commissioning process. These assumptions fit within the more general discourse about the importance of personalisation that is evident within the Health and Social Care Act (2012) and within public service policy more generally.13
The second claim made by the responders was that GP knowledge is ‘concrete’. By this it is meant that their knowledge is based on real experiences of particular services, not on statistical evidence. This is seen as particularly important in the NHS after the Francis report14 into poor care at Mid Staffordshire NHS Trust, in which failure to act on this type of concrete knowledge was highlighted as an important issue.
These attributes of GPs are hardly new, and GPs have been involved in many previous incarnations of ‘clinically-led commissioning’, including fundholding, total purchasing pilots, and practice-based commissioning (PbC). Therefore the important ongoing issue is how far this ‘fine-grained’ and ‘concrete’ knowledge about their population is deployed in a way that was not possible under previous arrangements. Responders stated that, in general, they believed CCGs provided better opportunities for use of clinicians’ knowledge to improve services than had been possible before. In particular, claims were made about the beneficial impact of GPs being ‘in charge’ and CCGs being ‘less bureaucratic’ than PCTs. This would certainly seem to be an explicit intention as CCGs were set up,12 but, as highlighted elsewhere, accountability arrangements for CCGs are complex,5 and the extent to which they manage to be more nimble and innovative is an empirical question yet to be answered.
In addition, questions arise as to whose ‘fine grained’ and ‘concrete’ knowledge is being used, and in what way? There is a danger here that CCGs will only heed voices of those directly involved in the CCG. This becomes problematic when the relatively small numbers of clinicians actively engaged are considered. A recent study by the King’s Fund and the Nuffield Institute15 also found that few GPs in leadership positions had undergone any kind of competitive process, and highlighted the difficulty of engaging more GPs in the CCG, the potential subsequent burnout of those involved, and a lack of succession planning.
There are also dangers associated with the implicit denigration of the systematic gathering of evidence associated with a public health approach. Public health is now under the auspices of local authorities, and many CCGs have yet to clarify fully the exact role that public health will play.16 Past studies of clinically-led commissioning suggest that GPs have historically struggled to move beyond local concerns to take a wider population view.9 The clear message received about the importance of individuals’ ‘fine-grained’ and ‘concrete’ knowledge suggests that CCGs may also struggle in this regard. It is too early to draw conclusions, however, and it is to be hoped that CCGs develop good relationships with their public health colleagues and work closely with health and wellbeing boards to mitigate this risk.
Further concerns arise with respect to patient and public involvement. The strong belief that GPs ‘know’ about the needs and concerns of their patients could lead to a failure to consult more formally. Two studies on service improvement in the English NHS by Gridley et al,17 highlight the patchy success in involving the public achieved by total purchasing pilots and PbC, noting that:
‘ … studies have shown consistently that GP commissioners are not good at public and patient involvement. In the total purchasing pilots, GPs saw themselves as “agents for their patients” without the need to actually involve them in decision making … ’
Finally, many of the responders (GPs and managers) raised concerns about sustainability and succession planning. Managers and GPs described unmanageable workloads, with late night and weekend working the norm, exacerbated by the heavy administrative burden imposed by the authorisation process. This is obviously not sustainable in the longer term, and the responders were beginning to discuss ways of working more effectively. It is clear that the question of exactly where and when clinical input is most useful is important, and needs to be explored in more depth.
Implications for research and practice
Together, this evidence suggests that, although the clinicians and the managers with whom they were forging close and productive working relationships remain committed and generally enthusiastic about the potential added value that clinicians are bringing to the process, there is a need for caution. Three areas require further exploration before firm conclusions can be drawn. The first is the extent to which the structures and processes associated with CCGs better enable the effective wielding of GPs’ claimed ‘unique’ knowledge, than in previous clinically-led commissioning and whether such knowledge can also enable system transformation. The second is the extent to which GPs are able to draw in wider voices, including their own ‘rank and file’ as well as public health experts and members of the public. Finally, research needs to explore in more detail the extent to which GP voices are needed in the different workstreams and processes that CCGs have developed. It is clearly unsustainable to have GPs everywhere and present on every occasion, and what might be called the ‘smart use’ of GP knowledge must be the aim. Managers told us that they valued the externally perceived legitimacy that close association with clinicians gave them; the prize must be to maximise this while not requiring GP attendance at every meeting, or GP comments on every document.
