GP commissioners: sole traders or private governments?

The Health and Social Care Act is creating major changes to the world of the GP, but little thought seems to have been given to the implications for GPs of designating clinical commissioning groups as statutory bodies. 

This development - which is central to the ambition for a clinician-led NHS – has major implications for the culture of the GP community and their relationship with the wider public. It places them in the position of determining local health policy, especially through the CCG’s function of allocating and rationing resources.

In a period of austerity, CCGs will be the focus of public attention when health needs are not met. 

Unlike other welfare professionals, such as teachers or social workers, GPs are not employees of the state but contract their services to the NHS. This considerable independence from government is reinforced by the highly technical nature of their training and strong identity as a profession. They are more akin to the legal profession, in this respect, as well as in the way in which they have developed as small or medium sized businesses. 

Historically, many GPs were sole traders or worked in small partnerships. It was not uncommon for practitioners to work single-handed, perhaps owning and even living in the property where they had their surgery and with a partner or other family member as the receptionist or administrator. 

Although there are still single-handed GPs, there has been a move to create larger practices, sometimes in a group structure, working with a wider primary health care team. A number of GPs have also been involved in practice-based commissioning, although this is somewhat different to the wider role that CCGs will be asked to play and lacks the public scrutiny to which CCGs will be subject.

Members only

Now, the advent of CCGs implies two further, sequential changes which will require GPs to behave in very different ways and which risk undermining their traditional status.

The first is the creation of a membership organisation or “club” of GPs in a geographical area. As with any new membership organisation, much of this first stage involves persuading potential members to join, engaging them in discussions about the organisation and purpose of the club, and establishing what benefits membership brings. The emphasis is on forming a workable constitution that enables the election of a management committee and gives the CCG a form of governance that can reasonably be regarded as legitimate by its current or potential GP members. 

Unlike most clubs, however, membership is not voluntary. CCGs will cover all GP practices. For this reason, the creation phase in some areas has taken time, as prospective CCGs vie for membership, amalgamate or are taken over by larger neighbours. This can result in a series of elections being held for management committee positions, and an increasing size in that committee. 

As embryonic CCGs continue to evolve, moreover, some practices may choose to leave one club and join another – particularly in urban areas where there may be multiple CCGs and scope to compare and contrast what membership of one CCG rather than another might offer to the practice concerned.

Community interest

The second and subsequent change is quite different.  Here the focus switches from internal matters to external relationships. The club needs to move towards authorisation as a statutory body, or “agency” whose role is to decide and implement public policy. This requires attention to its role as part of a system of public organisations working in the interests of the community, not its membership. This reorientation has significant implications. 

Take questions of transparency. Clubs typically are closed organisations and only members may attend meetings. Their business is conducted in private – unless there is some very significant dispute which hits the pages of the press. But statutory bodies need to be open to the public – to report their actions and permit questioning of their decisions. They are also subject to significant rules and regulations around freedom of information, conflicts of interest and standards in public life. These are not necessarily things with which general practice has had to engage in the past – and it may be that such duties will have to be undertaken with less management and administrative support than under the old PCT system. 

One reading of recent events is that GPs are being asked to form organisations that are both clubs with members and agencies with statutory duties – despite the fact that both these forms of governance require a different focus, imply a different underlying purpose and have different implications in terms of regulation and transparency (see table). Overlaid on top of this is the fact that GPs are not state employees but independent businesses. 

With this in mind, the development of CCGs could be seen as an unusual hybrid of statutory responsibilities and private enterprise – a form of “private government” in which the state cedes certain public functions to an independent body controlled by private interests, much in the way that municipal services in some high streets are now managed by businesses through an independently constituted business improvement district. This is much more than simple contracting out, since CCGs will be making health policy and resource allocation decisions at a local level – yet GPs may also be the delivery agents with a direct business interest.    

Protest risk

Beyond these complexities of role and accountability, there is considerable potential for CCGs to become the focus of political protest and legal challenge as they manage the dilemmas of limited and declining budgets. This goes with the terrain of statutory bodies. For all the talk of giving greater power to clinicians, CCGs will be political (small “p”) bodies because they will be making choices that advantage some sections of the community and disadvantage others. They are being asked to value some health and social outcomes over others. 

The role that GPs are being asked to play seems confused and potentially contradictory. Being corralled into “clubs” has been a difficult step for some traditionally independent GPs, while others see it as a logical development beyond group practices. The transition from “club” into an “agency” – with its public governance requirements – will be as challenging. 

The current system of emerging CCGs and PCT clusters provides a halfway house, but the reorientation from working as a professionally focused club to a statutory agency is a major step.  It will be especially important for the GPs leading CCGs to be able to negotiate the complexities of public debate and interaction with health and wellbeing boards and local government scrutiny committees that come with this new terrain if the potential of clinician-led health policy is to be achieved.

Jon Glasby is professor of health and social care and director of the Health Services Management Centre, and Chris Skelcher is professor of public governance at the Institute of Local Government Studies, both at the University of Birmingham.