It's crunch time for CCG pay

Throughout England, clinical commissioning groups are in the final stages of preparation for their formal start in April. For many, one of the outstanding issues is the terms on which clinicians will be involved – what they are expected to do and how much they should be paid. This is new territory and it is a major concern. The solution will influence the effectiveness and impact of these embryonic institutions.

Clinical involvement in CCGs takes many forms. This includes: GPs chairing the governing body, or working as accountable officer; GPs, nurses and secondary care representatives on the board; and clinicians appointed on a temporary or part time basis to lead developments in a pathway or a specialist area. 

In all these cases, it is important to secure the commitment of the right individuals – to respect the time and expertise they bring. And to encourage successive generations of clinicians to feel that involvement in commissioning is worthwhile. Of course, remuneration is only one aspect of that requirement, but it is clearly essential that major contributors feel they are fairly paid.

‘Employers want clarity and consistency, and they like to have a guiding policy rather than just a set of practices’

The starting point is not encouraging. Whatever their role, GPs, nurses and others are typically paid an hourly or sessional rate, agreed by predecessor PCTs. These vary from region to region, and even between neighbouring CCGs.

Some CCGs have a single rate; others distinguish between different levels of contribution. In some cases payments go to individuals, in others to practices. It is not always clear what is included – for example, how preparation for meetings is covered – or what expenses can be claimed.

Nor is it evident what the payments are for, in particular whether they are simply intended to enable backfill or in addition to provide some reward for the individual and reflection of their personal skills.

Under the circumstances, it is not surprising that remuneration committees are looking for some simple guidance which cuts through the detail. The example of GP contractors shows the problems they face.

Secure position

First, any GP acting as chair or as a clinical accountable officer will have to commit 50-60 per cent of their time to the role. Typically, they will have to reduce their share of the practice, to allow the partners to bring in permanent part time cover. It is a move which carries risks and loss of income.

Those who stand for election feel particularly strongly that they are giving up a known and secure position, yet they may later be deselected.

‘Any GP acting as chair or as a clinical accountable officer will have to reduce their share of the practice. It is a move which carries risks and loss of income’

Second, although CCGs know that the current reliance on hourly or sessional payments is unsustainable, it is unclear what the new arrangements should be. Some GPs will have to be put on employment contracts, because of the extent and nature of their work; some may continue to be paid for periodic services, by the hour or half day.

There may also be scope to retain some people on the same arrangements as non executive directors. But where the dividing line should lie between these three options is a matter of local and individual judgement.

Third, each CCG wants a direct input from a number of GPs, and in many cases they want seasoned professionals with deep knowledge of healthcare and the locality and previous experience of practice and community leadership. These will be among the highest paid in their profession. At the same time, CCGs have a cap on management costs and are acutely aware of the need to demonstrate cost control.

Fourth, GPs are used to seeing pay from a personal perspective. Their stance will often be: I earn £x in a given time period; if I work for the CCG, I might jeopardise future earnings worth £y; so my pay has to be at least £x+y. They may mention concerns about their share of the premises and loss of seniority payments or non-NHS income. Their logical conclusion is that payment arrangements should be matched to individual circumstances.

Steps to creating a policy

By contrast, employers tend to identify a rate for a particular type of work. Of course, they take account of the market price for the skills they need, and they sometimes have a bit of flexibility to accommodate an exceptional candidate, for example. But they want clarity and consistency, and they like to have a guiding policy rather than just a set of practices. They accept that the occasional candidate will turn down the remuneration offer, feeling it is too low.

CCGs mirror some of these employer characteristics, but they need to be sensitive to GPs’ views and concerns.

It is not easy to cope with and reconcile these pressures, but the steps in creating a policy are simple enough:

Step 1:  Analyse all relevant data, including current/recent payment practice and the cost consequences, the earnings of GPs and other clinicians in the region and the responsibilities and time commitments of the roles.

Step 2:  Agree principles which can inform and be used to test the design of the payment system. Some of these are obvious, such as providing value for money; others are true for most if not all CCGs, for example a requirement for simplicity; and certain principles are debatable, such as a wish to retain the most experienced GPs in the locality, or a view that some contributions by clinicians are worth more money than others.

Step 3:  Design the policy, ensuring it is clear what needs to be done, what the time commitments is and how it should be rewarded and the payment level. The implementation cost will have to be modelled – CCGs will want to know whether running costs will change and how this affects their targets – and the proposals tested with at least a sample of stakeholders.

Step 4:  Agree and implement, ensuring that the arrangements are well communicated, that there is proper governance and that there is provision for later evaluation and review.

Alongside these steps, questions will arise which run well beyond remuneration. CCGs have in effect decided the structure of their governing bodies without knowing how much they will cost.

Crunch time

It may come to a choice between offering a level of GP remuneration which isn’t enough to attract the best, or reducing the size of the governing body and keeping the remuneration level up. It may be better to have a smaller number of people, if their characteristics and contribution are right.

There is not much time to sort all this out. Some remuneration committees have met already; all should have agreed something by the start of April. But this decision will be the start of a much longer process of building a high performing CCG, headed by a coherent and effective governing body. 

In the next phase of development, CCG chairs and remuneration committees will have to ensure that, in return for their pay, clinicians deliver the required contribution. They will have to manage the performance of individuals and of the governing body as a whole. That too is new territory, and it will be no easier.  

Peter Smith is public sector reward expert at Hay Group