GPs in the driving seat?
The recent King's Fund report on emerging CCGs suggests that many GPs do not currently have a strong sense of ownership of their local CCGs. Member GPs are less likely to believe that their CCG is ‘owned’ by them when compared to the leaders of those CCGs. Whilst there was a great deal of support for what CCGs are trying to achieve, many of the GPs involved in the study felt that decisions being taken by their CCG did not always reflect their views.
More than half of practices said that being a CCG member has changed their clinical practice in terms of prescribing patterns, referral pathways and volume of referrals. The majority (59%) of survey respondents were unsure about the effect on patients that would result from changes to their referral rate, referral pathways, prescribing patterns or other clinical practices deriving from their being members of a CCG. A slightly greater proportion predicted a negative impact than a positive one over the next 12 months (19% compared with 16%).
How engaged are GPs?
The King's Fund report highlighted that levels of engagement with CCGs amongst GPs varied widely, as did the reasons for not being involved. For example, some GPs chose not to be involved because they were opposed in principle to clinical commissioning, whereas others wished to focus on their clinical role. The report stresses that sustaining the interest of engaged GPs as well as securing more engagement from others will continue to be a crucial issue for CCGs if they are to maintain their 'bottom up' ethos. As pointed out in a recent King’s Fund blog, whilst clinical commissioning does not necessarily involve substantial direct involvement from most GPs, it does need a widespread ‘buy in’ so that members have a sense of collective ownership and shared responsibility for the CCG’s success. This is particularly so in relation to the development of general practice itself. A challenge for clinicians leading CCGs will be to convert the goodwill existing in the GP community into active support and engagement.
There are also doubts amongst GPs that CCGs will improve the NHS, which may be due to CCGs themselves or a wider belief about the challenges facing the NHS.
Issues with workload
Whilst the King’s Fund report found that CCG leaders considered that engagement from GPs was significantly better than under practice-based commissioning and that the majority of GPs agreed with the principle of clinical commissioning, some GPs are, however, finding it difficult to engage with CCGs because of a lack of time or capacity.
Some GPs have already withdrawn from involvement with CCGs because they could not spend enough time with patients whilst helping run the groups, even through CCGs are mean to be GP-led. In a Guardian article, Dr Clare Gerada, chair of the Royal College of GPs, said that the difficulty of reconciling patient care with duties in their local CCGs means that it is inevitable that some GPs will pull out of the CCGs. Dr Kailish Chand, deputy chair of the British Medical Association, has stated that some GPs would be unable to perform both roles adequately as the extra work related to commissioning services cuts into the time they can spend with patients. The Guardian article also reports that NHS Clinical Commissioners, an organisation representing about 130 of the 211 CCGs, warned that “at practices across the country, workloads are at breaking point and GPs are ready to buckle under the strain”.
The chairs of Lewisham CCG and Hull CCG have already resigned, stating that increased practice workload as a result of the imposed GP contract have prevented them from continuing. In a recent Pulse article, Dr Tony Banerjee, chair of Hull CCG, who stepped down on 2 August, said that there had been ‘increasing pressures in both roles’, and told the Hull Daily Mail that ‘It has been so hard juggling my two roles as GP and as CCG chairman. The practice is getting increasingly busy … I just don’t have the time to do both, and I am a GP first and foremost.’ Dr Helen Tattersfield, former chair on Lewisham CCG, told Pulse that an increase in workload and the unpredictable payments from NHS England meant that she could no longer continue in her CCG role.
In addition, a Pulse investigation has shown that at least 30 GPs have resigned from their positions on CCGs boards since this April. Figures obtained under the Freedom of Information Act from 74 CCGs across England showed that one in three boards have had a GP member resign since April, with the overall proportion of GP CCG board members declining from an estimated 49% last year to 43%. Responding to Pulse’s findings, GPC deputy chair Dr Richard Vautrey said: ‘This is not a surprise and is a reflection not only of the workload and pressures of being involved in CCG work, but also of practice workload increasing dramatically – in large part as a result of the Government’s contract imposition – which means GPs are having to make the decision to spend more time in the practice to be able to cope with the workload there.’
Meanwhile, a Department of Health commissioned survey, the national GP worklife survey, has found that GPs are experiencing the highest level of stress recorded since 1998, with over half of those aged over 50 years saying they intend to quit direct patient care within five years, which is an increase of 30% in the last two years. Overall, almost a third of GPs indicated there was a considerable or high likelihood that they would quit direct patient care within five years. The report also found that most respondents agreed that GPs added value in commissioning roles, but were divided whether commissioning was part of their role as a GP. They expressed concerns about the impact that CCG introduction had had on their workloads and the time they could spend on direct patient care and continuity of care.