Since April, clinical commissioning groups (CCGs) have been allowed to take on extra responsibility for commissioning primary care services – generating controversy about whether GPs may profit from their decisions.
The new powers for GP co-commissioning enable CCGs to take over responsibility for planning and providing local primary care services, except for dental, optical and pharmacy. But the British Medical Association, the doctors’ body, and the Patients Association have both expressed concerns that there is a risk the changes may harm the doctor-patient relationship if some GPs are seen to be – or even suspected of – profiting from CCG decisions.
Under reforms introduced by the 2012 Health and Social Care Act, NHS England was originally given responsibility for commissioning primary care services and monitoring GPs’ contracts. Doctors and local NHS managers agreed this was not working well on the grounds that a centralised commissioning system could not properly reflect an area’s needs and priorities, which requires local knowledge.
But the move to hand commissioning powers to CCGs is a logical step and aims to link hospital and community services more effectively, argues Dr Michael Dixon, outgoing chair of the NHS Alliance, which represents primary care providers.
“It makes much more sense for CCGs to commission services locally to reflect specific needs as GP members have a much better understanding of how services need to be delivered, and should be able to do it more cost-effectively,” he says.
“The problem is that, just as this is beginning to happen, general practice is in its worst financial position for years and, although around 90% of patients’ contact with the NHS is through primary care, it is allocated less than 8% of the NHS budget.”
He adds that a new funding system being drawn up by NHS England should distribute the available resources more fairly. This will set new prices that hospitals can charge CCGs for treating patients, and also how much CCGs can pay for commissioning local primary care services.
The new system will allow CCGs to become both commissioners and providers of services, generating concerns that this could lead to conflicts of interest. As a safeguard, NHS England has issued guidance on good practice that all CCGs have to abide by, and all co-commissioning activities will be monitored nationally. Even so, the BMA still has concerns.
A BMA spokesman says: “Co-commissioning does have the potential to improve the delivery of patient care, but we have always been opposed to granting CCGs greater control over performance management of this process as it inherently raises concerns about conflict of interest between GPs on CCG boards and GP practices.
“Even the suspicion that decisions could be influenced by local relationships or factors has the potential to undermine the entire process. As set out in the BMA’s guidance [on the issue], which has never been adequately addressed by the government, we believe that decisions to move to delegated commissioning status should be made collectively with the full CCG membership and not concentrated in the hands of a few individuals.”
But Dixon believes that concerns about conflicts of interest have been blown out of proportion. CCG members are required to withdraw from voting on issues if they have a financial or practice interest in a tender. He thinks other means to provide services in a non-commercial way can be found, such as through social enterprises or community-interest companies.
Of England’s 211 CCGs, 196 expressed an interest in co-commissioning, and about 60 are believed to have taken on full delegated commissioning, which covers services such as podiatry and physiotherapy. Dr Steve Kell, chair of NHS Bassetlaw CCG, says it has already been able to make improvements to local services.
“We need to shift funding from hospital to community services, to enable people to remain as independent as possible and healthy in their own homes,” he says. “One step we have taken is to make £100,000 available per GP practice to employ a full-time pharmacist, to advise on prescribing, medication compliance and options for using new drugs. We think this will have a beneficial impact on patient services and will make savings in the long term.”
But he also sounds a note of caution on current trends: “My feeling is that NHS spending is going in the wrong direction in that more resources are being ploughed into secondary care, rather than into community services, where they are urgently needed if we are to keep people out of hospital and in the community.”
Dr Tim Moorhead, chair of Sheffield CCG, says the benefits of co-commissioning outweigh the disadvantages. He says: “We want to move services closer to the patient, and some practices may opt to provide more services themselves, but many will be more comfortable with the CCG planning community services locally, through existing community nursing teams, for example.
“We are aware of the potential for conflicts of interest – and even the perception of a conflict of interest could damage the doctor-patient relationship – so we want to be sure that we maintain a strictly arms-length relationship with service providers.”
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