Skip to main content

Main menu

  • HOME
  • ONLINE FIRST
  • CURRENT ISSUE
  • ALL ISSUES
  • AUTHORS & REVIEWERS
  • SUBSCRIBE
  • RESOURCES
    • About BJGP
    • Conference
    • Advertising
    • BJGP Life
    • eLetters
    • Librarian information
    • Alerts
    • Resilience
    • Video
    • Audio
    • COVID-19 Clinical Solutions
  • RCGP
    • BJGP for RCGP members
    • BJGP Open
    • RCGP eLearning
    • InnovAIT Journal
    • Jobs and careers
    • RCGP e-Portfolio

User menu

  • Subscriptions
  • Alerts
  • Log in

Search

  • Advanced search
British Journal of General Practice
  • RCGP
    • BJGP for RCGP members
    • BJGP Open
    • RCGP eLearning
    • InnovAIT Journal
    • Jobs and careers
    • RCGP e-Portfolio
  • Subscriptions
  • Alerts
  • Log in
  • Follow bjgp on Twitter
  • Visit bjgp on Facebook
  • Blog
  • Listen to BJGP podcast
Advertisement
British Journal of General Practice

Advanced Search

  • HOME
  • ONLINE FIRST
  • CURRENT ISSUE
  • ALL ISSUES
  • AUTHORS & REVIEWERS
  • SUBSCRIBE
  • RESOURCES
    • About BJGP
    • Conference
    • Advertising
    • BJGP Life
    • eLetters
    • Librarian information
    • Alerts
    • Resilience
    • Video
    • Audio
    • COVID-19 Clinical Solutions
Debate & Analysis

Primary care co-commissioning: challenges faced by clinical commissioning groups in England

Imelda McDermott, Kath Checkland and Anna Coleman
British Journal of General Practice 2018; 68 (666): 37-38. DOI: https://doi.org/10.3399/bjgp17X694325
Imelda McDermott
Health Policy, Politics and Organisation Research Group (HiPPO), Centre for Primary Care, University of Manchester, Manchester.
Roles: Research Fellow
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Kath Checkland
Health Policy, Politics and Organisation Research Group (HiPPO), Centre for Primary Care, University of Manchester, Manchester.
Roles: Professor of Health Policy and Primary Care
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Anna Coleman
Health Policy, Politics and Organisation Research Group (HiPPO), Centre for Primary Care, University of Manchester, Manchester.
Roles: Senior Research Fellow
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Info
  • eLetters
  • PDF
Loading

INTRODUCTION

The English Health and Social Care Act 2012 gave GP-led clinical commissioning groups (CCGs) responsibility for commissioning the majority of healthcare services for their registered population. However, responsibility for commissioning primary care services was given to a new national body, NHS England (NHSE),1 to avoid conflicts of interest1 and because of a perceived need for a standardised and consistent approach to commissioning.2 It soon became apparent that NHSE was struggling to move beyond a transactional approach to commissioning, focused on payments and contract management. When Simon Stevens took over as the Chief Executive of NHSE (April 2014), he advocated transferring responsibility for commissioning primary care services from NHSE to CCGs. Two years on, how have CCGs responded to their new responsibilities and what challenges do they face?

WHAT IS PRIMARY CARE CO-COMMISSIONING?

Co-commissioning is intended to support the development of integrated out-of-hospital services based around local needs. The scope of co-commissioning in 2015–2016 covers only general practice services, including: managing practice contracts; commissioning enhanced services and local incentives; establishing new GP practices; and approving practice mergers. It excludes individual GP performance management.

There are three possible levels of responsibility: greater involvement — CCGs have ‘influence’ in shaping primary care; joint commissioning — CCGs share responsibility with NHSE regional teams; and delegated authority — CCGs lead primary care co-commissioning. The policy intention is for all CCGs to ultimately take on delegated responsibility. However, in April 2015 a large proportion (87 of 209 CCGs) opted for joint commissioning, due to uncertainty over what co-commissioning would involve. One year on (April 2016), 115 of 209 CCGs (55%) have delegated responsibility, 68 (32.5%) joint commissioning, and 26 (12%) greater involvement.

Under delegated responsibility, CCGs must set up a Primary Care Commissioning Committee (PCCC) as a sub-committee of their governing body (GB). Unlike other sub-committees, which make recommendations to the GB,3 PCCCs have decision-making authority. To ensure transparency and avoid conflicts of interest (CoIs), PCCCs are chaired by a lay member and have a lay/executive majority.4

WHAT DOES IT INTEND TO ACHIEVE?

The NHS Five Year Forward View (FYFV) called for ‘new care models’ (NCMs) that envisage local commissioners and providers working together to break down the boundaries between primary, community, and secondary care.5 Co-commissioning is seen as a ‘key enabler’ to drive the development of NCMs. It is intended that CCGs will take a more integrated approach to commissioning,4 which will enable a shift of resources between sectors and facilitate the development of integrated organisations delivering NCMs. This is seen as a step towards ‘place-based commissioning’,6 which in turn will support planning by place for local populations. This will allow the local development of Sustainability and Transformation Partnerships (STPs).

STPs were first introduced in the 2016–2017 NHS planning guidance,7 being likened to a ‘route map’ representing different ways of working, bringing together health and care commissioners and providers. Although the 44 STP ‘footprints’, with leaders agreed by NHSE, are not statutory bodies and do not replace existing local bodies or change accountabilities, the importance of STPs as a vehicle for change is reflected in this year’s operational guidance,8 in which they form a key element. The criteria and requirements for CCG mergers have also been updated to include the need to align CCG ‘footprints’ to support STP delivery.9 In practice, STPs have been criticised for their lack of GP involvement.

DISCUSSION

What are the challenges associated with primary care co-commissioning in the context of these changes? One of the biggest concerns underpinning the original decision to give responsibility for primary care commissioning to NHSE was CoIs.1 However, in practice the need for policy ‘workarounds’ to solve the fragmentation introduced into the system by the Health and Social Care Act 2012 outweighed this concern. When primary care co-commissioning was introduced, it was argued that robust governance processes and decision-making transparency would alleviate CoIs.4 Two years on, concern over CoIs remains.10 There is little publicly available information on CCGs’ arrangement to manage conflicts, and NHSE has little data about how effectively they are doing this, relying on an exception-based assurance process and on Monitor as the system regulator.11 This raises questions about both transparency and local accountability. There is considerable variability in the processes used by CCGs to manage CoIs, ranging from minute taking and updating declarations of interest to no clearly defined process to manage breaches.12 However, with most CCGs claiming that their concerns centre on the perception rather than actual conflicts,6 having guidance that attempts to cover every eventuality risks making the process a tickboxing exercise.

Second, guidance suggests that CCGs will be responsible for liaising with the Care Quality Commission (CQC) about issues relating to practice performance, but will not be responsible for issues relating to individual GP performance, which remains with NHSE. In practice, these two things may not be easy to separate. For example, CQC inspections may flag up problems with individual GPs. CCGs are constituted as ‘membership organisations’, with every practice required to be a member. Performance managing their own members is challenging for CCGs, who have tried to make this more palatable by shifting the discourse away from ‘performance management’ to ‘peer-learning’ or ‘peer support‘.

Third, as GP federations and super-partnerships become more common it would make sense for GPs who have an appetite for lead roles to focus their efforts as providers of services rather than as commissioners. This may have significant implications for the sustainability of CCGs as clinically-led commissioning organisations, as they may struggle to fill GB places. Clinical leadership is already somewhat eroded by the fact that GP members do not form a majority on decision-making PCCCs. This means that significant decisions affecting local practices may be made that GBs cannot overturn.

Last, with no additional financial resource and a loss of managerial expertise since PCTs were abolished, CCGs are grappling with difficult organisational and structural issues around commissioning primary care.6 The previous transactional approach taken by NHSE left CCGs having to deal with considerable legacy issues such as getting hold of and understanding existing contracts.

CONCLUSION

The policy intention underlying the transfer of responsibility for primary care commissioning to CCGs was to allow more integrated commissioning, with the ability to shift resources around the system. CCGs are clearly enthusiastic about the opportunities this affords them, but it is as yet too early to tell how far this will be achieved.6 In terms of supporting the development of new ways to deliver care, our ongoing research suggests that the ability to vary local contracts for enhanced primary care provision has supported the incentivisation of practices to work together ‘at scale’. The hope is that practices will eventually move towards different organisational forms that could take on new contracts arising out of the FYFV, such as multispecialty community providers (MCP). STPs may require changes to the way general practice is delivered, and buy- in will be difficult to achieve if GPs have not been included in the discussions.

As these changes unfold, CCGs as membership organisations need to ensure that they bring their membership with them to maintain the clinical voice and local understanding.

Acknowledgments

We are grateful to our participants, who were very generous in allowing us access to their organisations at a time of considerable turmoil and change. We are also grateful to Dr Lynsey Warwick-Giles, Dr Donna Bramwell, and Dr Valerie Moran, who are involved with the project.

Notes

Provenance

Freely submitted; externally peer reviewed.

Competing interests

The study was funded by the Department of Health via its Policy Research Programme. The study formed part of the programme of the Policy Research Unit in Commissioning and the Healthcare System. The views expressed here are those of the researchers and do not reflect the position of the Department of Health.

  • © British Journal of General Practice 2018

REFERENCES

  1. 1.↵
    1. Department of Health.
    (2010) Equity and excellence: liberating the NHS (The Stationery Office, London) [White paper].
  2. 2.↵
    1. NHS Commissioning Board
    (2012) Securing excellence in commissioning primary care (NHS England).
  3. 3.↵
    1. McDermott I,
    2. Checkland K,
    3. Coleman A,
    4. et al.
    (2016) Engaging GPs in commissioning: realist evaluation of the early experiences of clinical commissioning groups in the English NHS. J Health Serv Res Policy 22(1):4–11.
    OpenUrl
  4. 4.↵
    1. NHS England
    (2014) Next steps towards primary care co-commissioning (NHS England, London).
  5. 5.↵
    1. NHS England
    (2014) Five year forward view (NHS England).
  6. 6.↵
    1. McDermott I,
    2. Checkland K,
    3. Warwick-Giles L,
    4. Coleman A
    (2016) Understanding primary care co-commissioning: uptake, scope of activity and process of change (PRUComm, Manchester).
  7. 7.↵
    1. NHS England
    (2016) Delivering the forward view: NHS planning guidance 2016/17–2020/21 (NHS England).
  8. 8.↵
    1. NHS England,
    2. NHS Improvement
    (2016) NHS operational planning and contracting guidance 2017–19 (NHS England).
  9. 9.↵
    1. NHS England
    (2016) Procedures for clinical commissioning groups to apply for constitution change, merger or dissolution (NHS England).
  10. 10.↵
    1. Robertson R,
    2. Holder H,
    3. Bennett L,
    4. et al.
    (2015) Primary care co-commissioning: a survey of members’ views of their CCG and its role in primary care (King’s Fund, Nuffield Trust, London).
  11. 11.↵
    1. National Audit Office
    (2015) Managing conflicts of interest in NHS clinical commissioning groups (NAO, London).
  12. 12.↵
    1. NHS England
    (2016) Co-commissioning conflicts of interest audit: summary report (NHS England).
View Abstract
Back to top
Previous ArticleNext Article

In this issue

British Journal of General Practice: 68 (666)
British Journal of General Practice
Vol. 68, Issue 666
January 2018
  • Table of Contents
  • Index by author
Download PDF
Article Alerts
Or,
sign in or create an account with your email address
Email Article

Thank you for recommending British Journal of General Practice.

NOTE: We only request your email address so that the person to whom you are recommending the page knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Primary care co-commissioning: challenges faced by clinical commissioning groups in England
(Your Name) has forwarded a page to you from British Journal of General Practice
(Your Name) thought you would like to see this page from British Journal of General Practice.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Primary care co-commissioning: challenges faced by clinical commissioning groups in England
Imelda McDermott, Kath Checkland, Anna Coleman
British Journal of General Practice 2018; 68 (666): 37-38. DOI: 10.3399/bjgp17X694325

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero

Share
Primary care co-commissioning: challenges faced by clinical commissioning groups in England
Imelda McDermott, Kath Checkland, Anna Coleman
British Journal of General Practice 2018; 68 (666): 37-38. DOI: 10.3399/bjgp17X694325
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One
  • Mendeley logo Mendeley

Jump to section

  • Top
  • Article
    • INTRODUCTION
    • WHAT IS PRIMARY CARE CO-COMMISSIONING?
    • WHAT DOES IT INTEND TO ACHIEVE?
    • DISCUSSION
    • CONCLUSION
    • Acknowledgments
    • Notes
    • REFERENCES
  • Info
  • eLetters
  • PDF

More in this TOC Section

  • SAFER diagnosis: a teaching system to help reduce diagnostic errors in primary care
  • An Australian reflects on the Collings report 70 years on
  • Emergencies in general practice: could checklists support teams in stressful situations?
Show more Debate & Analysis

Related Articles

Cited By...

Advertisement

BJGP Life

BJGP Open

 

@BJGPjournal's Likes on Twitter

 
 

British Journal of General Practice

NAVIGATE

  • Home
  • Current Issue
  • All Issues
  • Online First
  • Authors & reviewers

RCGP

  • BJGP for RCGP members
  • BJGP Open
  • RCGP eLearning
  • InnovAiT Journal
  • Jobs and careers
  • RCGP e-Portfolio

MY ACCOUNT

  • RCGP members' login
  • Subscriber login
  • Activate subscription
  • Terms and conditions

NEWS AND UPDATES

  • About BJGP
  • Alerts
  • RSS feeds
  • Facebook
  • Twitter

AUTHORS & REVIEWERS

  • Submit an article
  • Writing for BJGP: research
  • Writing for BJGP: other sections
  • BJGP editorial process & policies
  • BJGP ethical guidelines
  • Peer review for BJGP

CUSTOMER SERVICES

  • Advertising
  • Contact subscription agent
  • Copyright
  • Librarian information

CONTRIBUTE

  • BJGP Life
  • eLetters
  • Feedback

CONTACT US

BJGP Journal Office
RCGP
30 Euston Square
London NW1 2FB
Tel: +44 (0)20 3188 7679
Email: journal@rcgp.org.uk

British Journal of General Practice is an editorially-independent publication of the Royal College of General Practitioners
© 2021 British Journal of General Practice

Print ISSN: 0960-1643
Online ISSN: 1478-5242