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PCT clones ‘would be a scandal’


5 November 2011

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The prospect of clinical commissioning groups (CCGs) in England simply replicating soon-to-be-abolished primary care trusts (PCTs) would be a “scandal”, the president of the National Association of Primary Care (NAPC) warned delegates at the recent GP Business conference at the Birmingham NEC (held on 4 October).

Keynote speaker Dr James Kingsland, a GP and National Clinical Commissioning Lead for the Department of Health, said there ought to be a “public outcry” if CCGs were to mimic the health structure he said is being “largely dismantled”.

The prospect of clinical commissioning groups (CCGs) in England simply replicating soon-to-be-abolished primary care trusts (PCTs) would be a “scandal”, the president of the National Association of Primary Care (NAPC) warned delegates at the recent GP Business conference at the Birmingham NEC (held on 4 October).

Keynote speaker Dr James Kingsland, a GP and National Clinical Commissioning Lead for the Department of Health, said there ought to be a “public outcry” if CCGs were to mimic the health structure he said is being “largely dismantled”.

A longstanding champion of clinical commissioning, Kingsland said CCGs were better off “starting small” so local practice teams could focus on the needs of their local populations and make the essential efficiency gains required by the health service over the next four years.

More than 300 GPs and practice managers attended the national conference in Birmingham exclusively focusing on non-clinical matters affecting general practice.

“Let’s be clear: CCGs are the constituent practices,” Kingsland told delegates. “If we recreate the bureaucracy that this legislation is trying to get rid of, if we recreate 150 CCGs with about 300,000 populations, their should be a public outcry because it would be a scandal.”

Central to the government’s reforms is the idea that local clinicians will be accountable for achieving better outcomes for their patients. Some critics of the Health and Social Care Bill have suggested that the emerging structure of the reformed health service – with the central authorising body of the NHS Commissioning Board waiting in the wings, in addition to Health and Wellbeing Boards and advisory clinical senates – would not radically reduce the bureaucracy that is the government’s stated objective.

Following his address, Kingsland told GP Business: “I don’t believe centralism is the agenda – nor do I think in any sense that a new centralism would work.”

His opening speech was dominated by talk of the need for the health service to make 4% efficiency savings by 2015. Kingsland insisted this would not be achieved by a centralised system, but by “every practice” in “every community” effectively reducing wasteful spending.

He told delegates that the “bottom-up” reforms had to be a fundamental change to previous delivery, and that practices would have to become “more productive with what is protected”.

He said: “The idea that we’ll solve the [efficiency] problem by producing CCGs that are bigger organisations than PCTs and by putting a few clinicians in the place of expert managers is one of the biggest myths flying around the system.”

The financial challenge facing the NHS has been described as unprecedented – not least by NHS Chief Executive Sir David Nicholson, who has told GP Business that “we have never delivered savings on this scale before or have been as ambitious about what we need to do” (see interview this issue).

However, Kingsland insisted that the efficiency savings challenge was “not unprecedented” in general practice. He claimed that a King’s Fund report showed that in the fundholding era, practices that had managed their budgets had achieved 4% efficiency gains over seven years.

“That’s what we really need to get back to [in order to deliver] what is expected by these reforms,” he said. However, he warned this would be no easy task. “Can we change behaviours in every consultation, every day, in every general practice in every community clinic in England? Because if we can’t, we 
will fail.”

A key message at the Birmingham event was that, whatever changes to the Health Bill that may arise from the debates in the House of Lords, the direction of travel was not going to change where local commissioning organisations are concerned.

In his keynote speech, Kingsland dismissed suggestions that a successive government might turn back the clock on GP-led commissioning, saying there was “no alternative” to the central thrust of the reforms.

This was supported by a separate presentation from Caroline Kerby, Managing Partner of a northwest London practice and clinical lead for her local CCG. Kerby told delegates that “the primary care genie is out of the bottle. There is no going back – this will affect every practice 
in England.”

Kingsland told GP Business that the idea the bill would be dismantled and that the government would make a ‘U-turn’ was unrealistic, since changes are already in place. “A U-turn to what?” He said. “We’ve largely dismantled the old system. Part of it is crumbling. There’s nothing to go back to.”

The sense that GPs are somewhere ‘between’ structures was supported by another speaker. Dr George Solomon, GP Lead and Chair of Black Country CCG, spoke of the establishment of his commissioning group, from being a sub-committee of the PCT, and its development. But he started by admitting that continuing debate over health policy meant “we’re never sure if what we’re doing today will fit with what will be announced tomorrow”.

Solomon’s CCG covers 19 practices and is responsible for a population of 100,000. He stressed the value of engagement with both the local community and with local healthcare professionals and managers. “Clinical leadership doesn’t mean clinicians leading everything,” 
he said.

Indeed, the CCG has a collaborative ethos, having set up a ‘Vision and Development Group’ comprising representatives including patients, GPs, practice managers and practice nurses who feed back on CCG commissioning plans. Solomon said the move to clinical commissioning had resulted in closer ties with patients. “I’ve never seen as much involvement from our patients as I do now – the amount of interest and enthusiasm has been quite surprising.”

The event’s focus was not just on commissioning, however. Also debated was another major general practice reform – the abolition of geographical boundaries, scheduled to take place in April 2012.

Dr Robert Morley, Executive Secretary of Birmingham Local Medical Committee and a regional GPC representative, gave an overview of the government’s plans – as part of the “choice and competition agenda” – and the British Medical Association’s (BMA) objections.

“Practice boundaries have been enshrined in legislation since the start of the NHS. This is revolution, not evolution,” he said. The BMA has concerns that giving patients the right to register with any practice in England – regardless of where they live – would create issues including potential disruption of the Carr-Hill formula, home visit arrangements (“there is no such thing as a patient that does not require home visits,” he said) and a “commuter shift” to urban GP surgeries leading to “destabilised and overwhelmed practices”.

While many delegates voiced agreement with these concerns, Kingsland told GP Business he did not believe that free choice would create such overwhelming problems for practices. “I think we’re blowing it out of proportion,” he said. “Most patients would have the understanding that there’s a geographical limit to what they sensibly could have.”

While admitting that the impact would be greatest on practices in commuter belts, he urged GPs to focus their services outwards. “The bottom line is we’ve got to remember what general practice is for. It’s a service for patients, not a service for GPs,” he said.

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