It could work, but poor implementation, GP disengagement and cuts threaten to smother this health service restructuring
Following the passage of a deeply divisive health bill, we are now in the middle of the authorisation of clinical commissioning groups (CCGs), the bodies that have been given the tricky task of making clinical commissioning a reality. Up and down the country, CCGs are putting forward their credentials and making the case to the new NHS commissioning board that they are ready and able to commission services for their local populations from April 2013. The board will be responsible for directly commissioning services worth around £20bn and for allocating more than £60bn to more than 240 CCGs.
Clinical commissioning, as a concept, is one that the British Medical Association (BMA) has been advocating for many years, as the merits of moving the control of services closer to patients and local clinicians are obvious. It could, if done properly, lead to an NHS that is more responsive to the needs of the local community, while empowering doctors to get more involved in shaping the services they deliver. Many doctors and other healthcare professionals have untapped experience and talents that could be harnessed for the benefit of patients.
Unfortunately, this proposed new dawn has already been tarnished by the protracted passage of the health bill and the ongoing financial squeeze that could mean there are fewer services available for CCGs to commission. Many GPs are concerned that they could become the administrators of NHS cuts as they are handed responsibility for decimated budgets. The NHS Act 2012 gives CCGs the authority to decide to whom they will provide a service, and what service they will provide. They will be under no obligation to ensure that a whole range of services are available to their catchment population. (There is already rationing of services such as hernia, cataracts and hip or knee replacements). The NHS Act also enables CCGs to enter into joint ventures with private companies to outsource most work to private companies with vested interests, beyond the scope of full public scrutiny.
It is a factor that the government refuses to address despite it looming over the entire clinical commissioning process.
This worrying mood has been worsened by a number of practical problems emerging on the ground during the early stages of the authorisation phase, particularly with CCG constitutions which will decide how each CCG will operate. GPs are reporting back to the BMA that some GP practices are being pressured into signing constitutions at short notice with barely any time to check how their practice, and patients, will be affected.
Others are flagging up that many GPs have a lack of basic information which has left them bemused about the whole process. Government pronouncements about how its reforms will involve doctors more in planning healthcare will fall totally flat if rank-and-file doctors are left scratching their heads on the sidelines. Participation rates among GPs in many CCGs is already reported to be low.
There is still time to make clinical commissioning work, but it is in real danger of becoming smothered by a toxic combination of poor implementation, GP disengagement and NHS cuts. This represents a real first challenge for the new health secretary, Jeremy Hunt. He must take action urgently to address the implications of the rushed authorisation phase that could undermine the whole project. And on funding, he must show his mettle by fighting to protect the NHS budget so that CCGs do not simply become the vehicle for cutting back our health service.
Time will tell whether Hunt is willing and able to meet these challenges
• This article presents the author’s personal views and not those of the BMA