Engaging GPs in commissioning: realist evaluation of the early experiences of Clinical Commissioning Groups in the English NHS

Theory 1 (GPs’ knowledge about patient experiences) and Theory 2 (GPs’ knowledge about services)

Our interviewees suggested that GPs’ knowledge about patients and available services would enable them to identify and deal with problems early on and improve service design. These theories share a common theme with all previous clinical commissioning schemes which also rested upon the claim that GPs are better informed about patients’ needs than managers as they have access to practice-level data and direct feedback from patients.^14–16

We identified some of the mechanisms by which GPs may contribute more fully to the commissioning process. CCGs need to ensure that there is a facilitative environment which assures GPs that it is safe and easy to express their concerns, and contribute to or attend meetings. Important contributing factors included good chairing of meetings and a willingness to vary the meeting format to maximize the opportunity for active engagement. For example, Site D decided to use a ‘select committee enquiry’ format in one of their meetings with hospitals to encourage GPs to question and contribute. Good communication was important, particularly given the complexity of CCGs’ internal structures. There needed to be proactive communication with clinicians to ensure that they understood which forums to address their concerns to, which meetings were happening where, and what topics would be covered on the agenda.

CCGs also need to actively seek out the views and experiences of clinicians not actively involved in the CCG on a day-to-day basis. Whilst GPs’ personal knowledge of patients and services was valuable, it needed to be supported with aggregated qualitative data such as that relied upon by managers. There also needs to be significant preparation prior to meetings, which includes giving GPs task-specific information before the meeting.

Our interviewees also claimed that GPs ‘see the whole system’. However, our observations showed that GPs’ knowledge was often pertinent to a particular service and they did not necessarily have insights into a full range of services, nor about how services work in general. Service reconfiguration and a proliferation of hospital providers make it difficult for individuals to understand the full range of services available locally. Our sites recognized this, with many seeking to establish a searchable database with information on the range of available services. Overall, clinical voices were valuable in providing contextual details and information as to whether services were being delivered as intended but they required additional information from managers in order to understand fully the pattern of available services.

The concept of clinical leadership is central to all models of primary care-led commissioning. Under GP fundholding and PBC, GPs were encouraged to engage in commissioning. GPs were the undisputed leaders in fundholding and assumed most of the responsibility of running the scheme including budgeting, contracting and liaising with external stakeholders such as the Health Authority (HA) and local providers. ¹⁷ Similarly, most PBC consortia were dominated by GPs and had a degree of delegated decision making power. ¹⁴ Under Primary Care Trusts (PCTs) and HAs, by contrast, only a select number of GPs were engaged, either in an advisory capacity or not perceived as influential, with GPs struggling to exert control over decision making. ¹⁸ They were used primarily as a sounding board or source of factual information. ¹⁹ Total purchasing pilots had no organizational template so there was substantial variety in terms of the nature of interaction between GPs and their constituent HA. ²⁰ In practice, projects that were badged as ‘commissioning total purchasing pilots’ had meaningful clinical input (albeit if the input came from lead GPs) and more autonomy and influence over decision making. ²¹

Policy rhetoric presented CCGs as different from previous initiatives because GPs would take full commissioning responsibility. ¹ Our study shows that GP involvement in CCGs looks very similar to previous clinically led commissioning. Most GP leaders who are actively engaged in CCGs are the usual suspects, who have previously held a leadership role; CCGs had considerable difficulty in enthusing new GP leaders. ⁸ However, while previous clinical involvement was limited to those in leadership positions, in CCGs this can occur at different levels of the organization. Some CCGs had separate clinical and management teams while others had a GP majority overseeing the commissioning function. Some CCGs have localities, neighbourhoods or a Council of Members who may or may not be given devolved budgets and responsibility. This makes it difficult to draw general conclusions about GP involvement as the extent to which the new system has enabled better or more robust GP involvement varies in different CCGs.

Theory 3 (clinician-to-clinician discussions)

Whilst initiatives such as PBC had involved GPs in the commissioning process, ¹⁴ some argued their lack of statutory power had limited their effectiveness. ²² Similarly, only 20% of Primary Care Groups involved clinicians from primary and secondary care. ²³ By contrast, our participants claimed that CCGs have enabled GPs to become more involved in contracting and made provider clinicians more likely to engage. This suggests that GPs’ clinical experience gives them knowledge and experience which they can use to speak to clinicians outside the CCG in ways which improve commissioning by, for example, challenging existing ways of doing things. GPs’ clinical experience gives them the authority to talk about clinical issues and to challenge providers, if required, in a way that managers could not. In contrast to Theories 1 and 2, in which CCGs are seeking their members’ frontline knowledge to be used in commissioning process, Theory 3 is about engagement with the wider body of clinicians who are external to the CCG.

In spite of attending many pathway development and contracting meetings, in which hospital clinicians were present, we did not observe many instances in which GPs brought their clinical knowledge to bear in challenging their hospital colleagues. In fact, one of our study CCGs had made the decision to only send managers to these meetings as it was not regarded as a good use of GP time. We only observed one instance where hospital clinicians’ behaviour was apparently influenced by the presence of GPs. In one of the quality and performance meetings we attended, it was noted by those present that the relevant hospital’s Medical Director had not been attending the meeting regularly. GPs in the group expressed their disquiet about his absence, suggesting that they regarded it as unacceptable, as there were a number of important issues on the agenda such as serious safety incidents. This challenge has led the Medical Director to attend subsequent meetings.

The fact that we did not observe many instances of GPs engaging with and challenging their hospital colleagues does not mean that these conversations are not happening. It could be that the conversations are happening informally, outside of the formal meetings that we observed. That we rarely observed GPs in contracting meetings suggests that the claims made by those espousing this theory – that clinicians bring a unique and important focus to meetings with providers – was not much experienced in practice.

We identified some of the mechanisms which underlie the successful attempts made by CCGs to achieving clinician to clinician discussions. Site A had been trying to get their members to own the CCG since they were authorized. To achieve this, the CCG decided to invite a hospital providing urgent care to attend the membership meeting to enable GPs to challenge the hospital’s failing performance. However, when the meeting took place, no such challenge occurred. In contrast, in Site D where a similar meeting was convened, GPs had a challenging discussion with the hospital staff. The CCG decided, as a trial, to organize the meeting in a ‘select committee’ style, with GPs as committee members and the hospital representatives as witnesses providing an account of their services. Before the meeting, the chair had primed some GPs in the room with questions to ask. These GPs read out the questions when prompted to do so by the chair, and this was followed by questions from other GPs from the floor. The panel was then given the chance to answer. The meeting turned out to be quite a challenging session, with the panel becoming somewhat defensive in their answers at times. By the end of the meeting, they identified a list of issues to work on as a group (including hospital clinicians, GPs and managers). Hence, careful preparation prior to the meeting and the role of the chair enabled the GPs to have challenging discussions with clinicians from the hospital.

Our study shows that GPs can contribute significantly to commissioning by using their clinical experience to engage effectively with other clinicians but that this requires careful preparation and management and probably only occurs on a limited scale. To engage effectively with the wider clinical community outside the CCG, the formal architecture of the CCG and the operation of statutory authority were not necessary. Some of our sites had established informal groups across the health economy which focussed on a variety of issues including high-level strategy and service development ideas. These groups have no formal or statutory role. The key mechanism underpinning this is that those present should be senior enough within their own organization to make binding commitments on their behalf.

Theory 4 (clinician–manager symbiosis)

Our participants claimed that GPs and managers work together more effectively than they would be able to alone. Managers would formulate and write strategies and business plans while GPs would assist in clinical input and engage with other clinicians. Mechanisms which enable this theory to work include a history of cooperation. Where this history did not exist, careful appointment procedures in which GPs were fully engaged could support the development of new close working relationships. GPs and managers should also recognize that they had different skills and contributions and that they felt able to challenge one another. The status of the CCG as a membership organization was crucial and as the confidence that GP members have towards the GP–manager team working on their behalf. The experience of success and having joint responsibility for programme delivery was important both in developing the close and supportive relationship between the two individuals and in bringing the wider membership along with the process.

This GP–manager pairing was evident under PBC. Most consortia had some kind of managerial support provided by the primary care trust and the extent to which GPs truly led the agenda depended on the dynamics of the relationship between assigned managers and GPs. ¹⁴ The assigned managers were facilitative and supportive, acting as enablers to promote clinical leadership. These pairings were also evident in PCTs, although in that case, it was between the Chief Executive and Professional Executive Committee (PEC) chair. The PEC chair was felt to be the most influential member. ²⁴ Hence clinical leadership was limited predominantly to one GP who held considerable power within PCTs. The distinctive feature of some CCGs was that these clinician–manager pairings were evident at multiple levels, from the Governing Body to Localities and within different workstreams. It was clear that many of those involved had a long history of working in a particular locality in different roles. A sense of a shared and enduring local commitment seemed to be important in enabling trust. However, in cases where a preexisting relationship did not exist, having the clinicians involved in the recruitment process had been important, as it enabled them to feel that they had chosen their managers.