'New insights could help CCGs be clear on population health services'

Clinical commissioning groups display varying levels of confidence on what functions and structures best meet both the expectations for authorisation and their patients and population. These should coincide but time will yet tell.

Several interesting insights have begun to emerge that might help GPs and managers in CCGs to navigate through some of the uncertainties – one of which continues to be the population size to be covered. We can readily understand the economies of scale that a larger organisation can bring. However, it is also worth reflecting on not just what will give efficient and economic management, but what will give the best quality service to the public.

None of this is new, but what new insights could help CCGs’ delivery? Perhaps we have the answer already, as shown in December when the King’s Fund hosted the health economist Jamie Robinson of Berkeley to share learning from medical groups in the US.

Professor Robinson shared three main points which underscore some of the recent messages from both the NHS Alliance and National Association of Primary Care.

First, is the sense of ownership by practices and the inevitable relationship that stimulates success – specifically, GPs willingly following good leadership. Anyone with experience of working with practices will know that GP leadership can be a very precarious presumption for a doctor. Being an effective CCG leader is not just about understanding and communicating government policy. More important is that GP colleagues (and other primary care deliverers) see their leaders as being active on their behalf.

Second, Professor Robinson identified competent management within medical groups as being vital to survival. He cited the varied competencies and abilities that many medical groups had in financial management, care management processes and IT. Interestingly, an early predictor of a successful group was one that considered the potential risks of rapid growth and planned for the consequences.

Here in England the learning from this insight is more complex in its application. Superficially, it could be seen as a further argument for size and economies of scale, but the US example is as much about provision as it is about commissioning.

In our NHS we have an increasingly puritanical divide between “make and buy”, with the consequent result that the organisational forms that support primary care provision (that is, the large number of practices supporting thousands or tens of thousands of patients) do not mirror CCG coverage (hundreds of thousands of patients). In short, while GP businesses maintain and evolve their own breed of organisational form and CCGs evolve another, the alignment of interest and ownership may well continue to be under tension.

This is not a plea for GP practices to assume corporate levels of merger and acquisition. Nor would I advocate that CCGs cover fewer than 100,000 people. The residual question to be answered in my mind is, how do you get consortia of practices to own CCG footprints without feeling that those footprints are imposed from the top down?

Let’s look at the third insight, which may signpost opinion on the value of a different approach.

Hospital use and how to reduce it in preference to new localised and community services has been a doctrine in the NHS that keeps academics, politicians and managers awake at night. Probably less so for most hard-working clinicians at the NHS front line.

In California, however, inappropriate hospital use was reduced because medical groups comprised some specialists as well as family doctors. The model of multispecialty medical practice in California enables more care to be provided in community settings, with hospitals being used only when necessary.

By contrast, in England, it could be observed that the commissioner/provider divide has led to fractures in communication and in the working practice between hospital based and primary clinicians. The notion of clinical senates may address this, but is this perhaps where we ignore the benefits of localism?

One issue that does galvanize different practice interests is practices’ relationships with their acute provider. With Monitor’s support, if the CCG relationship became an integral and significant influence within hospital governance, would this provide the focus needed for practices to act cohesively at a scale that benefits both cost and service quality for patients?