Clinical Commissioning Groups

The creation of Clinical Commissioning Groups (CCG’s)

One of the most fundamental reforms introduced by the Health and Social Care Act 2012 was the creation of Clinical Commissioning Groups composed of GP’s in a given Geographical area who will receive their funding from the National Commissioning Board. Originally seen as statutory bodies led by general practitioners, later guidance makes clear that most of their work will be undertaken by private corporations who will facilitate their transition to “freestanding enterprises”.

Added managerial responsibilities on GP’s

The avowed aim was to give to GP’s the power to power to influence commissioning decisions for their patients but with this comes additional managerial and accounting responsibilities that lie outside their core training as health professionals. This inevitably reduces time spent on meeting patient needs. As CCG’s are legally obliged to contract out services to “any qualified provider” there are added challenges posed by large private corporations with powerful legal and contracting departments who will seek to sign only those contracts which limit their risks and maximise their profits[Reynolds L & McKee M (2012). “Any qualified provider” in NHS reforms: but who will qualify? The Lancet. Mar. 379;9821. p.1083‐1084] at the expense of CCG’s. The CCG’ must command sufficient legal expertise to identify all potential risks and losses and negotiate hard to avoid bad deals. From the point of view of GP’s, it makes no sense for them to spend their time negotiating and administering contracts for referrals, and still less for them to bear financial risk for their expensively ill patients.

Example of Care UK taking legal action against Clinical Commissioning Groups

Care UK, the UK’s biggest private healthcare provider demanded an investigation into four GP-led Clinical Commissioning Groups to remove the elective care contract and award it to a local NHS Health Trust. The contract covers a range of services, including general surgery, orthopaedics and ophthalmology, for 965,000 people. Care UK, which has supplied elective care services in the area for several years, said the CCGs’ decision to take away the contract was discriminatory. Regardless of the grounds of their appeal, this example suggests that resort to legal redress could result in both stressful and expensive outcomes for CCG’s whose decisions against the interests large private companies .

To conclude: with so many added challenges on time and expertise which GP’s were neither trained for, nor in many cases wanted, many CCG’s contract out these managerial functions to private consultants and for-profit companies. As a result, only a quarter of accountable officers were GPs in October 2014. Only half of GP practices said they felt involved in CCG decision making processes.

As well as creating pressures for GPs to deny needed care, the new internal market creates barriers to joint working between primary and secondary care practitioners. The incentives embedded in the new system pit GP’s against hospitals and other secondary care providers, with the latter trying to increase charges to cover their overheads and make profits, and the former trying to stop them[Clare Gerada, Lucy Reynolds, Martin McKee:From family doctor to referral gatekeeper: the future of GP practice].

Current situation-CCG’s

pressure to rationalise healthcare and cuts to budgets
The extent to which CCGs will be able to refuse enrolment by general practices and individual patients is still unclear but what is becoming increasingly clear is the pressure to rationalise health care: a recent investigation by the GP Magazine Pulse revealed that a third (36%) of GPs are facing new constraints on services to which they were previously able to refer such as surgical treatment of conditions like ganglions or carpal tunnel .

A separate Pulse request under the Freedom of Information Act to 108 CCGs in June 2015 found that since the two years they have been in existence 39 had cut their budgets for 2015/16 and 23 had frozen them at last year’s level . As part of these figures 19 CCGs have been ordered by NHS England to devise emergency plans to cut their budget deficits. Some examples of what this entails include:

  • NHS Luton CCG says, ‘when appropriate, patients must stop smoking and/or undergo a weight loss programme’ before certain elective procedures.
  • NHS North Staffordshire CCG said hearing aids will no longer be routinely provided for patient diagnosed with a mild hearing loss. Campaigners from Action on Hearing Loss labelled the decision ‘cruel’
  • NHS Great Yarmouth and Waveney CCG demands that smokers give up, and obese people lose weight prior to hip and knee replacement therapy and this could be ‘rolled out to other surgical procedures’ .
Northumberland Clinical Commissioning Group hands over responsibilities to ‘accountable care organisation’

On 30th July 2015, Northumberland CCG handed over its responsibilities to an unspecified provider led ‘accountable care organisation‘ – effectively handing over its budget and doing away with the current split between commissioner and health service provider. It is the first CCG to do so. The CCG will exist in a significantly diminished form and restrict its role to high level population based outcomes for the ACO. It will have no commissioning role .