As the NHS reaches its 75th birthday, general practice represents something of a policy paradox: it is both highly visible, dominating headlines with perceived shortcomings and failings (Mroz, Papoutsi and Greenhalgh, 2022), and yet strangely invisible, with the most recent NHS reorganisation in England barely touching on its role. For example, in the latest Health and Care Act (Department of Health and Social Care, 2021) mention of general practice is confined to a few references to how it might be commissioned, with nothing at all about its form or function. Most strikingly, the most visible aspect of current primary care policy – an additional contract which provides funding for groups of GP practices to work together in networks – is not mentioned at all in the Act.

In part this dichotomy arises from the historical position of general practice in the NHS. In 1948, general practice was established not as an integral function of the hierarchical new NHS, but as a separate service, provided to the NHS by independent contractors (Peckham and Exworthy, 2003). This independent status has been both a strength and a weakness of general practice ever since (Lewis, 1998). Lauded for the fact that it may support innovation, and usefully allowing the central NHS to avoid providing premises, it has also been identified as problematic, generating unwarranted variation and difficulties in integrating primary care with other sectors (Chapman and Groom, 1999; Jones et al, 2015).

In terms of the themes set up in Chapter 1, general practice is perhaps an outlier, insulated by its independent status from the more significant NHS policy switches around competition or managerialism. Nevertheless, general practice policy since 1948 has seen a shift towards a more atomised approach (Norman, Russell and Merli, 2016), with the professional ideal of providing person-centred relationship-based care in ongoing tension with an approach which seeks to identify and manage biomedical problems in the most efficient way possible (Checkland et al, 2008).

In this chapter we consider general practice in the context of its history, and offer some thoughts about the future which take account of the unique status of primary care as both the entry-point to other services and as a semi-detached quasi-independent service.

Introduction

As discussed in Chapters 1 and 2, one of the central tenets of the HSCA 2012 was the desirability of increasing the involvement of GPs (and other clinicians) in the commissioning of services for their patients. This ideological commitment – based upon belief and founded, in part at least, upon an implicit denigration of managerial work (in order to increase control over the NHS and commissioners), had far-reaching consequences in the design of the reforms. For example, the initial separation of responsibility for commissioning primary care services from secondary and community services was deemed necessary because of the potential for conflicts of interest, whilst the creation of CCGs as ‘membership organisations’ had, as seen in Chapter 3, significant implications for their organisation and governance. The initial White Paper, ‘Equity and Excellence’ (Department of Health, 2010a: 9) was relatively non-specific about the expected benefits of clinical leadership of commissioning. It was argued that:

The document suggested that the proposals would: ‘liberate professionals and providers from top down control’; shift decision making closer to patients; enable better dialogue between primary and secondary care practitioners; and ensure that service development had real clinical involvement. However, the mechanisms underlying these perceived benefits were unstated. Furthermore, it was claimed that, whilst previous incarnations of GP-led commissioning (which in the UK go back to the creation of ‘GP fundholding’ in the 1990s) had delivered some benefits, these had been limited by the failure to give those involved complete autonomy and real budgets. The creation of CCGs, it was argued, would remedy these problems and ‘liberate’ clinicians to significantly improve care.

Introduction

The changes introduced by the HSCA 2012 represented a substantial redistribution of responsibilities within the English NHS. This included the compulsory membership of CCGs for GPs, via their practices, which was linked to a quality payment, defined locally by the CCG, for those successfully carrying out commissioning responsibilities. The policy was intentionally permissive when first introduced, with, for example, the size and composition of CCGs not imposed. In a letter to GPs in September 2010, Sir David Nicholson, Chief Executive of NHSE stated that: ‘We would want to enable new organisations, and particularly [CCGs], to have the maximum possible choice of how they operate and who works for them. It is important that GP practices be given time and space to develop their plans to form commissioning consortia’ (Nicholson, 2010). During October 2010, groups of GPs were invited to join aspiring CCGs, with the help of local SHAs – organisations that led the strategic development of the local health service and managed PCTs and NHS Trusts (NHS Digital, 2018) – to begin to organise themselves. By June 2011, there was over 90 per cent coverage of CCGs in England. Over time the policy became more constrained, with recommendations made for CCGs not to cross LA boundaries, optimal population coverage being suggested, and maximum management budgets being set. In supporting GP practices towards CCG establishment, NHSE published guidance setting out what should be considered when putting in place the necessary arrangements (NHS Commissioning Board, 2012c). The key elements of the guidance included:

• • The need to have a defined geographical footprint in order to commission for populations not registered with a GP practice.

• • The need for CCGs to be established as ‘membership organisations’, with GP practices as members, collectively making decisions about how the CCG should be set up and function.

• • The issues to be addressed in a constitution, including: arrangements to ensure transparency; provision to hold meetings in public; appointing an audit and a remuneration committee; arrangements for relevant subcommittees if required.

• • Safeguards against conflicts of interest.

• • The key issues to be considered in appointing GB members, including the appointment of lay membership along with a hospital consultant and a nurse from outside the CCG's geographical area.

Introduction

This chapter provides a brief contextual summary, setting out the organisation and governance of commissioning in the NHS. It gives an overview of commissioning from the creation of the internal market in the late 1980s to its consolidation pre-and post-HSCA 2012, and highlights the important changes which were brought about by the HSCA 2012. The chapter highlights the programme theories underlying the internal market and the HSCA 2012, in particular the commitment to competition as a means of improving services and the expected benefits of greater clinical involvement in commissioning. The architecture of commissioning following the HSCA 2012 is outlined and an overview of developments since the Act is presented.

It is perhaps important to note here that clinical involvement in commissioning has been variously referred to as ‘clinically-led’ and ‘GP-led’. In its earliest manifestations (GP fundholding) there was a clear policy commitment to the involvement of local GPs (primary care physicians) in commissioning. As noted in Chapter 1 this policy was driven by a belief in the value of local clinical knowledge, rather than by any evidence of its value. Over time, emphasis in policy has shifted between ‘GP-led commissioning’ (such as fundholding, PBC) and ‘clinically led commissioning’ (such as Primary Care Groups [PCGs]). The use of the wider term ‘clinically led’ has been used by policy makers to signal a commitment to the wider engagement of other clinicians such as nurses and hospital consultants, often in response to representations from other professional groups. Thus, in their first iteration, CCGs were explicitly intended to be GP-focused, but during a consultation period the rules were amended to mandate the involvement of both a nurse and a hospital consultant on CCG governing bodies, and policy documents reflected this by referring to ‘clinically led’ commissioning. However, in practice, clinically led commissioning has generally meant GP-led commissioning, with the involvement of other clinicians tokenistic at best. In this book, for consistency, the term ‘GP-led commissioning’ is used, but acknowledge that policy has, at times, tried to promote a wider clinical engagement beyond local GPs.

Internal market/purchaser– provider split – the origins of ‘commissioning’

The NHS was established initially in 1948 as a hierarchical public Organisation.

Introduction

The aim of this book is to bring together in one volume the most important research which the Policy Research Unit in Commissioning and the Healthcare System (PRUComm) has undertaken during the period 2011 to 2018. PRUComm is a multicentre research unit based at the London School of Hygiene and Tropical Medicine (LSHTM), the University of Manchester and the University of Kent. It is led by Professors Stephen Peckham (LSHTM and Kent), Kath Checkland (Manchester) and Pauline Allen (LSHTM). PRUComm was funded (following an open competition) by the Policy Research Programme of the English Department of Health and Social Care (DHSC) (that is, the English Ministry of Health) from 2011 onwards to provide evidence to the DHSC to inform the development of policy on commissioning and the healthcare system. The analytical work supports understanding of how commissioning operates and how it can improve services and access, increase effectiveness and respond better to patient and population needs.

Commissioning

The term ‘commissioning’ is used in the context of the quasi-market structures in the English National Health Service (NHS), which will be explained in detail in the following chapter. Briefly, ‘commissioning’ can be understood as ‘the process of assessing needs, planning and prioritising, purchasing and monitoring health services, to get the best health outcomes’ (NHS England, 2018a). In other words, commissioning focuses on the demand side of the NHS quasi-market (where organs of the state make decisions on behalf of patients), as opposed to the providers of care, such as hospitals. The research extends to analysing the structure and operation of the NHS healthcare system as a whole, focusing on how commissioning can be used to influence providers’ behaviour. Clearly, the concept of commissioning is not confined to the English NHS. Quasi (or actual) markets were introduced into many English public services in the 1990s and the necessity for the state to undertake demand-side activities on behalf of (or in conjunction with) citizens became widespread (Le Grand and Bartlett, 1993). For example, social care has also been subject to marketisation (Forder et al, 2004). Although the term commissioning is not always used internationally, many countries have developed institutional structures for their public services in which commissioning functions are undertaken either by the state (for example, in the Italian healthcare system) (France et al, 2005) or social insurance funds (for example, in the Dutch healthcare system) (Rutten, 2004).

The period since the passing of the HSCA 2012 has been one of change and disruption for the NHS and at the time of writing in 2019 it seems unlikely that this turbulence will diminish in the near future. While the LTP (NHS England and NHS Improvement, 2019) published in January 2019 provides some indication of the future direction of commissioning, the lack of specific detail and guidance leaves the Plan open to interpretation. The main thrust of the LTP is to increase the emphasis on collaboration and integration at local level at the expense of competition, but its provisions about commissioning itself are not clear. The structural changes introduced by the HSCA 2012 pursuant to the twin policies of increasing clinical involvement in commissioning and accelerating market forces have had large effects on the practice of commissioning across the NHS. The government also emphasised the need for local freedoms to determine how services should be delivered in relation to the choices and needs of patients and greater public and democratic accountability (Department of Health, 2010a). In addition, while the focus of less attention, the shift of public health from the NHS to LAs discussed in Chapter 8 has also had a profound effect on the commissioning and delivery of services. The broad range of PRUComm's research projects has revealed a series of common themes, which are also found in other research on developments during this period.

As highlighted in previous chapters, since the introduction of changes following the HSCA 2012 there has been a large increase in the complexity of health system governance. The number of bodies undertaking commissioning has increased in two ways: NHSE, PHE and LAs all have a role in commissioning aspects of health care, in addition to CCGs, which were the successor to PCTs; moreover, CCGs are smaller organisations than PCTs so there are many more of them. While the shift to CCGs and LA commissioning appears to fit with the White Paper's language of localism and decentralisation, freeing local commissioners from central control, the reality has been somewhat more mixed.

Introduction

Under the HSCA 2012, NHSE was responsible for commissioning primary care services. However, in 2014 CCGs were invited to volunteer to take on responsibility for commissioning services from their member GP practices in addition to their wider responsibilities for commissioning acute and community services. This chapter draws upon research into the establishment of the ‘co-commissioning’ of primary care services by CCGs, which was conducted from April 2015 to April 2017 (McDermott et al, 2018). This chapter starts by exploring the history of primary care commissioning and financing in England and discusses the broad policy objectives which underpinned this significant change in CCGs’ role and scope. It examines whether and how the policy intention works in practice and explores factors affecting development of the policy, highlighting concerns over conflicts of interest, challenges in implementing the policy and unintended consequences. For clarity, the term ‘primary care commissioning’ is employed because this is the term used throughout the relevant policy documents. While globally the term ‘primary care’ often refers to the full range of out-of-hospital services, including community nursing and so on, in the UK, for the purposes of commissioning, a distinction is usually made between primary care (including GP services, and services provided by dentists and optometrists), secondary care (including standard hospital services), community care (including community nursing and a range of community-based services such as physiotherapy, occupational therapy and so on) and specialised care (including highcost, low-volume services). Following the HSCA 2012, CCGs were responsible for commissioning secondary and community care, whilst NHSE was responsible for primary and specialised care. In this book, references to primary care services predominantly mean primary medical care provided by GPs, as these are the services at which commissioning policy has been directed.

History of primary care commissioning and financing in England

The current primary care system in England is based on GPs being the contractors to the NHS rather than employees. This system was born out of the decision made at the establishment of the NHS in 1947 (Checkland et al, 2018b). This enabled GPs to remain independent of the NHS in a legal sense (although in reality the majority of practices depended overwhelmingly on NHS income), minimising their opposition to the NHS (Lewis, 1997; Peckham and Exworthy, 2003).