Ben was CEO of Nene CCG for 8 yrs. He was a Director of an acute trust and has run national improvement programmes. He is a founding director and Principal Consultant of Ockham Healthcare, which he describes as ‘a platform for change’.
After the shambles of the RCGP 2022 GP document, it is refreshing to find a great report on the future of general practice. The Nuffield Trust and the Kings Fund have produced a document, ‘Securing the Future of General Practice: New Models of Primary Care’.
You can find the document here. It promotes fundamental changes to the organisation and delivery of general practice, which include linking together practices in federations, networks or merged partnerships. It builds the rationale for this on a clear understanding of the case for change, which it articulates really well.
I think there are some areas where the report overly complicates the required change process. But before I get into that I just want to reinforce that I think this is a great report, and one that should immediately become required reading for all CCG and NHS England staff!
First the good. The report is really keen not to dictate to practices what they need to change into. Instead it is keen that we have clarity on the functions required of primary care. It suggests 5: improving population health, particularly amongst those at highest risk of illness or injury; managing short term non urgent episodes of minor injury or illness; managing or coordinating care for those with long term conditions; managing urgent episodes of illness or injury; and managing and coordinating care for those nearing the end of their lives.
I would fully support this approach. It sets a clear outcome and leaves the form required to develop organically rather than be imposed. What it does say is that general practice will require skilled facilitation, business planning and professional support (e.g. legal, financial, estates) when developing plans for extending service provision. The universal experience from elsewhere is that all underestimate the support that is required.
I guess where my view differs from that of the report is the lack of ambition the report demonstrates for the role of CCGs in the transformation process. Indeed, the report suggests that the very existence of CCGs is detrimental to the development of general practice, because the, ‘capacity for strategic work available is taken up by clinical commissioning responsibilities’!
Let us be clear. No one is, or has ever been, better placed to facilitate the transformation of the autonomous, independent business units that are general practice than the CCGs that are membership organisations of those very practices. CCGs understand general practice in ways that it is not possible for other organisations to, simply because it is made up of practices! Its leaders are GPs! I know I am stating the obvious, but this point seems lost on many outside of CCGs.
The report suggests that the required transformation cannot rely on the ‘heroic’ model of leadership where it falls to a small number of single individuals carrying those around them. As such it suggests two things: a ‘national framework’ to guide strategic direction; and new contractual and funding options to sit alongside the existing contract.
Here I think the report is wrong. Yes practices need support. But developing a framework feels like a process that will delay change starting and that in reality will not drive change. In fact I am not sure who it will actually help. It talks about a new contract that NHS England will offer practices covering end of life, mental health, long term conditions, older people, and children. But these areas all fall within CCG budgets. It does give an alternative that CCGs could commission additional services from general practice. But we already can, so I am not clear what exactly we would be changing?
I agree the changes will not happen by themselves. What I think we need is two things. First we need a strong partnership between NHS England and CCGs to enable the commissioning of an extended range of services, in as innovative a way as possible. We discussed what this might look like recently. You can find it herehttp://ccginformation.com/how-commissioning-can-transform-general-practice/ .
The second is to demonstrate to practices that it is possible to make these changes, to support the willing, and to create a critical mass that will become a tipping point for wider change. We need to spend our time not on frameworks or contracts but actively supporting the process of change, and it is CCGs ultimately who must use the unique position they are in and take the lead role in this.
The report is excellent, but it is 100% wrong to suggest CCGs are a barrier to this change. On the contrary we are the solution, and the ones who must take on lead responsibility for the task of implementing the core suggestion of the report: the transformation of general practice.
This article was first published on July 19th, 2013 on www.ccginformation.com
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