As the first wave of clinical commissioning groups come through the authorisation processs, some questions remain about how they will operate. Nigel Edwards and Chris Naylor look at what we know so far, and what remains unanswered

The first wave of clinical commissioning groups have now passed through the authorisation process - the mechanism to ensure they are fit for purpose and ready to take over from primary care trusts.

‘Reliance on the interests and enthusiasms of individuals can be powerful but may lead to inconsistency in terms of approach’

Over the past year, the King’s Fund has worked with around a third of all CCGs, taking part in mock panels and development centres to help them prepare for authorisation. This work has helped to shed light on several things: what their priorities are, their strengths, development needs and how they will operate as organisations. It also identified a number of significant unknowns.

What we know

There is now much more clarity about the priorities CCGs have identified. For first-wave CCGs, long-term conditions come top of the list, followed by integration, developing partnership working and urgent care. Prevention and public health issues also feature high on the lists of many groups.

There is also, unsurprisingly, a focus on specific clinical conditions of direct interest to member practices or to key people within the CCG. This rather organic approach does mean there may be more potential to make rapid progress in some of these areas than has been possible in the past, as the involvement of clinicians in these projects seems to make a positive difference to the development and acceptance of ideas.

Reliance on the interests and enthusiasms of individuals can be powerful but may lead to inconsistency in terms of the approach taken. At the same time as CCGs are conducting detailed work on individual areas, we also saw an encouraging tendency for their commissioning approach to be much more focused on outcomes rather than the specification of inputs and the performance management of providers on process measures.

It is not clear how far this very diverse approach will continue or whether there will be pressure for a more uniform approach to national priorities − and whether this will dampen some of the enthusiasm there is currently.

Learning new relationships

CCGs are having to learn new relationships, even in areas where the practice-based commissioning arrangements were well established − becoming a CCG changes the nature of these and has also brought some new people into leading roles. 

CCGs seem to be good at developing these relationships, although for some the legacy of poor relationships between PCTs and some providers can still be an issue that continues to get in the way of productive work.

There is a question about whether this dependence on good pesonal relationships could be a vulnerability as at present there is often reliance on a few individuals to develop and sustain these.   

‘In many CCGs there was no evidence of a plan B even for high risk situations’

The governance of CCGs is complex and in some senses they are unusual organisations. Many have highly complicated structures with many shared roles, complex alliance arrangements and locality groups. Accountability and responsibility may need to be more clearly articulated and there is still significant uncertainty about the role of the governing body and the executive, not least because GP members sitting on governing bodies may also be involved in driving commissioning in particular areas or leading projects.

In some cases there are ongoing debates regarding the relative roles of bodies which exist to represent practices directly versus the governing body, or of localities versus the central executive team.

Many have put significant thought into what it means to be a membership organisation but they create considerable challenges. In practice, what it means to be a membership organisation will be quite different in a CCG with more than 100 member practices compared to those with as few as 10.

Short-term thinking

Perhaps the most difficult challenge is the tension between being a board member and having some representative role or even being the head of a locality group. This will be hard to manage and dealing with it and the potential for conflicts of interest may require rather more procedural formality than has previously been necessary.

Engagement with the public, beyond practice engagement groups, has also been a challenge. There are some well developed approaches but in general there is more to do here and in some cases this is still underdeveloped and rather passive in its approach.

Many CCGs seem much stronger on immediate priorities and opportunities for relatively small-scale improvements than they are on longer term strategy. There is a need for more scenario planning and preparation for situations in which their intended strategy proves difficult to deliver. In many CCGs there was no evidence of a plan B even for high risk situations such as a very difficult large-scale change being delayed or overturned. 

This is not very surprising given their starting position and the scale of the task they are addressing, and it might be less of an issue if the strategy function in the form of the strategic health authorities had not been abolished.

To deal with issues of large-scale acute strategy, CCGs will need to learn to work together using federated approaches and other models of relatively soft coordination.

‘The character of the relationship between CCGs and the commissioning board is one of the main unknowns’

The track record of this is not encouraging. PCTs often struggled to make these kinds of arrangements work, with the requirements of individual PCT accountability often trumping collective agreements.

Not all CCGs that will need federated arrangements have them in place, and those that do have varying levels of formality. History suggests if this vacuum is not filled then the NHS Commissioning Board regions and local area teams will move to fill it and there is the risk that, as has happened in the past, power will be shifted upwards. 

What we still don’t know

One important unknown is how CCGs will deal with primary care. The priorities they are developing will mean they will need to deal with variations in practice and have difficult conversations with colleagues about compliance with pathways, access or even about performance.

There are very encouraging signs that they are willing to take this on and be significantly more challenging than the primary care trusts they replace, although they appear to be using financial incentives less often than was the case under practice-based commissioning.

CCG leaders point to examples where the power of peer-to-peer conversation has already had results and the qualitatively different dynamic of this compared with a PCT manager-to-practice conversation. There is some appreciation that this may have some implications for them personally in terms of their relationships with colleagues.

Some CCGs are also encouraging practices to work more closely together as providers rather than just as localities supporting commissioning. This raises an important question about the nature of the relationship with the board and how far this will be able to support new approaches − in particular the development of new local contracts. The board may be required to take some very difficult and demanding action to support CCGs in this area. 

The character of the relationship between CCGs and the commissioning board is one of the main unknowns. There is an expectation that the nature of day to day performance management will be different but a significant number of accountable officers and most CCG staff are drawn from PCTs and as such may be accustomed to a particular type of relationship.

New culture

The challenge will be to develop new approaches that reflect both the new culture and structures. The strong presence of GPs on the board and the added dynamic created by health and wellbeing boards may support these relationship changes by giving the CCG more ability to challenge the commissioning board. 

One interesting question this raises is the nature of the board’s accountability to CCGs for how they discharge their role in specialist commissioning and the management of primary care contracts.

This remains unresolved but if the board does not control the growth of specialist commissioning spending or respond to the need to improve primary care it may find it hard to hold CCGs to account for outcomes.

‘The transition from the independent culture of general practice to a bureaucratic, more regulated system requires a new mindset’

There are also personal challenges for GPs on the new boards, not least the need for them to sustain what have often been very high levels of personal commitment through an extremely demanding process.

They are learning a new language and different ways of operating, navigating local politics and adapting to how a more formal, rules-based organisation works. As they learn, it will be a challenge not to become overreliant on the chief officer.

The transition from the independent culture of general practice to a bureaucratic and more regulated system requires a new mindset and the concern is the requirements for even a minimum process will deter some GPs from engaging in commissioning.

CCGs are highly diverse and as such it is hard to generalise, but there do appear to be reasons for optimism − among the people leading the new bodies there are many highly motivated and impressive individuals.

The biggest unknown is whether there are enough of these people and whether they can sustain the high level of effort that is needed in increasingly difficult times.

Nigel Edwards is a senior fellow, leadership development and health policy, and Chris Naylor is a fellow, health policy, at the King’s Fund