Clinical Commissioning Groups were introduced by the 2012 Health and Social Care Act. The role of GPs within the NHS and their relationships with NHS managers are changing as a result, explains Julia Segar.
The NHS is dealing with severe challenges at present, with A&E in crisis and bed blocking preventing the release of some patients who might live in community-based accommodation – if more were provided.
Simon Stevens, the new chief executive of NHS England, published in October his Five Year Forward View, which put forward an outline blueprint for an NHS that deals with the pressures it is facing by focusing more clearly on the provision of services in the community by groups of GPs working together with other organisations.
Realisation of Simon Stevens’ vision will require a different relationship between clinicians and managers, who must form effective partnerships. This builds on the work already being done by GPs within Clinical Commissioning Groups (CCGs).
A key feature of the Health and Social Care Act 2012 was the creation of CCGs, which transferred responsibility for 60% of the NHS budget in England – £65bn of spending – to GPs. It is GPs who now lead the process of planning, designing and purchasing health services for their local populations.
The rationale for this reform was the notion that GPs are on the ‘frontline’ of patient care, so they know and understand their patients’ needs and, in turn, are trusted by their patients. Our research has examined the impact of the creation of CCGs on GPs and NHS managers, and how their roles have changed as a consequence.
Clinicians with managerial roles are not new, but the difficulties of having to balance allegiances to patients and to NHS bodies must be recognised. We argue that the latest reforms have brought about a step change within the NHS. The roles and responsibilities required from CCG leaders go way beyond the managerial roles in predecessor organisations, such as GP Fundholding and Practice Based Commissioning. GPs, as part of CCGs, now have much wider commissioning responsibilities: they control and spend real money and there are no buffer organisations – such as Primary Care Trusts – between GPs and the patients they serve.
In addition, CCGs are membership organisations and GP membership is compulsory. GPs with roles in CCGs must balance their position as ‘frontline’ clinicians with other roles as leaders, managers and budget holders. Our research highlights some of the tensions and unease that comes with marrying the needs of individual patients with population-wide concerns about budgets, priority setting and possible de-commissioning of services.
In the words of one of the GP CCG board members that we interviewed: “What does worry me is the very difficult financial situation we’re in. Huge quick savings that we’ve been tasked with, and the potential difficult rationing decisions we’re going to have to make, and how that’s going to sit with the public in the future and the newspapers and that sort of thing.”
These are prescient remarks in view of news stories in December which reported that NEW Devon CCG will restrict routine surgery for the morbidly obese and for smokers in an effort to cut expenditure.
We also considered the shifts in responsibilities for managers as their positions change and job losses are absorbed. Managerial teams have been fragmented with an associated loss of organisational memory and connection to local communities. In addition, managers’ role in leadership has changed as GPs have shouldered more responsibilities and managers have been placed into subordinate positions.
Managers that we interviewed voiced concern about clinicians’ ability and desire to take on managerial work. We noted a reluctance among GPs to take on CCG leadership roles and there are some early signs that GP representation on CCG governing bodies is falling.
There is much academic interest in the nature of institutions and how they change. Scott suggests that it is useful to understand institutions as being made up of three pillars and we have used this theory to examine the changes taking place as GPs have formed themselves in CCGs and taken on commissioning responsibilities.
The first pillar of institutions refers to rules, regulations and sanctions: these are fairly easy to understand. The second pillar refers to the norms and values held by individuals and the resulting behaviour that ensues. Here our interest has been in the roles of GPs and managers and how these have shifted in the wake of reforms.
Scott’s third pillar is the least tangible and refers to the meanings associated with institutional life: these are often things that we take for granted and only notice when profound change brings them to our attention. If we travel abroad and encounter different healthcare systems we become conscious of our own ‘cultural templates’ of how healthcare works here at home. It is this third pillar that is, in particular, under pressure through the introduction of CCGs.
Our research has highlighted that the roles of GPs and managers are changing as CCGs develop. These changing identities will also change the character of the NHS itself. We pose a key question: do these changes begin to erode the third pillar of the institution and change the ties that bind GPs and managers to the NHS?
The research was carried out as part of the programme of the DH-funded Policy Research Unit in Commissioning and the Healthcare System (PRUComm). The views contained in the research findings and this blog are those of the authors.