INTRODUCTION
Ever since Clinical Commissioning Groups (CCGs) were formed in 2013, they have often been perceived by grassroots GPs as the ‘dark side’. It is human nature to perceive statutory bodies as obstacles in our daily working lives and that can set an anti-institution philosophy in our mindsets. Over the years, CCGs have received a lot of criticism from both providers and regulators. CCGs have a finite budget set by NHS England and they have to purchase health care from a variety of providers while staying within their financial constraints. This process leads to many decisions which imply rationing, and often, these are then conveyed to the end user — the patient — by frontline staff working in provider organisations. As frontline staff can be conveying difficult messages to the patient, without having a sense of control over the implicit or explicit rationing process, this can lead to stakeholders dissociating from the commissioning process and often creates a ‘them versus us’ impression.
Some GPs have engaged with commissioning and provided leadership within their CCGs and wider health economies. It is our hope that after reading this article, readers will realise that if more GPs were to engage with commissioning, then we can be the voice of our colleagues and patients, and influence the delivery of better outcomes within the finite NHS budget.
BACKGROUND
Commissioning is the continual process of planning, agreeing, and monitoring services. Commissioning is not one action but is comprised of a range of activities, including:
assessing the health needs of the local population;
planning health services to meet the identified needs;
procuring the services as per the assessment and planning; and
monitoring the quality of the services delivered for the population.
It is clearly evident that three out of the four above mentioned activities require clinical input and with our collective clinical wisdom and experience, services can be commissioned to deliver an effective healthcare service for our respective populations.
Each of the almost 7000 GP practices in England are now part of a CCG. There are approximately 191 CCGs altogether commissioning care for an average of 226 000 people each.1 The health and social care act of 2012 aimed to put GPs at the forefront of the commissioning process. This would be achieved by the following key changes:
CCGs are clinically led bodies and GPs are responsible for providing this clinical leadership;
The CCG Council of Members comprises GPs from most, if not all, member practices; and
All CCG Governing Bodies have GP members.
For the commissioning structures to deliver on their promise of truly clinician-led commissioning, it is vital that all GPs get involved in their CCG, hold their CCG to account, and involve colleagues from across secondary care and public health in the commissioning process.2
WHY SHOULD GPs GET INVOLVED WITH COMMISSIONING?
GPs have been involved in providing health care from the cradle to the grave, and possess the core skills of community orientation and delivering community based healthcare. We understand the health needs of our community, the resources required for delivering a service, and have experience of working with a diverse workforce. In the current climate of workforce shortages and financial constraints, change is necessary and this innovative approach has to come from the grassroots, which places GPs in the driving seat.
If GPs don’t engage and understand clinical commissioning, then changes in models of care will be developed without our voice, and there is a strong likelihood that those models will fail due to lack of a locality based approach. Primary care services provide nearly 90% of activity in the NHS making it imperative for us to have a say in reshaping our NHS services. This is an opportunity we can’t afford to miss and as David Paynton talks in his podcast on commissioning,3 we need to ensure that the mantra ‘no decision about us, without us’ is pursued.
It is perspicuous that patient experience and outcomes are better when services commissioned are designed on population-based health models rather than disease models. We, as GPs, provide health care to our registered population, encompassing prevention, health promotion, diagnosis and management of long-term conditions, and mental health services. This insight into health provision is invaluable in the commissioning cycle and we must engage with our CCGs to help in constructing an efficient integrated healthcare system.
HOW DOES THE NHS LONG TERM PLAN INVOLVE PRIMARY CARE IN COMMISSIONING?
The NHS Long Term Plan was published recently and it sets out how the £20.5 billion budget settlement for the NHS will be spent over the next five years, envisioning an NHS fit for the future.4
The plan focuses on the following key points:
ensuring everyone receives the best start in life by continuing to improve maternity safety, including halving the number of stillbirths, maternal and neonatal deaths, and serious brain injury by 2025;
helping communities to live well by continuing the prevention of major diseases, including heart disease, strokes, and dementia; diagnosing cancer and respiratory diseases earlier; and, spending more on mental health with a strong focus on community-based physical and mental healthcare; and
helping people to age well by increasing funding for primary and community care in order to improve out-of-hospital welfare with a wide range of professionals working together in teams; improve dementia care; and, give people a greater say in the care they receive, especially towards the end of their life.
The recently announced new GP contract framework5 marks the biggest general practice contract change in over a decade. It will be essential to deliver the ambitions of the NHS Long Term Plan through strengthened collaborative general practice that works with other services.
One of the major reforms has been the introduction of primary care networks (PCNs). These networks are groups of practices working with other health and care organisations covering populations of between 30–50 000 people and are set to play a crucial role in the delivery of the Long Term Plan’s ambitions. The plethora of professionals in a network will include pharmacists, physiotherapists, and physician associates, thus making the multi-professional community team a reality. These networks will contribute to integrated care systems’ (ICS) discussions and plans, driving the delivery of integrated primary care at community level.
In order for the Long Term Plan to be a success, GP practices will have to drive the change, as commissioners and providers. This conflict of interest between the roles of commissioning and provision of services will need to be robustly managed. Primary and community care transformation is at the heart of the plan and primary care networks will need to work closely with commissioners to identify the needs of their respective populations and build an infrastructure that addresses those needs. This is an excellent opportunity for GPs to engage with networks, localities, Sustainability and Transformation Plans (STPs), and ICSs, and influence commissioning for health outcomes for their respective populations. Population health management will be the linchpin for primary care, secondary care, and social services to work together. The key enablers will be workforce, IT and digital, and the blurring of organisational boundaries to promote health and manage illness. GPs will need to be at the heart of these strategic conversations and their implementation, as we have a holistic understanding not only of our patients, but the challenges of their wider local healthcare environment.
SO WHAT HAPPENS NEXT?
We hope that this editorial will make GPs enthused, lead them to engage with their local CCGs and participate in designing their local PCNs to manage the health needs of their respective local populations. It is paramount for our College to provide more avenues for the understanding of commissioning processes and enable members to discern and participate in these. We are hopeful that raising the profile of commissioning will lead towards its inclusion in the GP training curriculum as it is vital for our future workforce to grasp an understanding of commissioning to become truly effective healthcare leaders.
Notes
Provenance
Commissioned; externally peer reviewed.
Competing interests
The authors have declared no competing interests.
- © British Journal of General Practice 2019
REFERENCES
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