Within the English NHS, Clinical Commissioning Groups (CCGs) were designed to increase clinical involvement in commissioning – it was thought that GPs’ knowledge of patients’ needs and local health systems would drive more patient-focused commissioning built around local needs.  This new report asks if greater involvement has worked and if so, what specifically has worked?  It could be argued that there is a fair amount of variation across CCGs in terms of clinical engagement so this report asks some pertinent questions.

Method

The research team used a realist methodology which recognises that approaches work differently depending on a range of contextual factors and aims to help understand what works, for which people, in what cirumstances.  As part of the research, the team undertook 4 case studies, holding 42 semi-structured interviews with clinicians and managers and observing 48 meetings.

Specifically, the research asks:

• what value do GPs bring to commissioning? (outcomes)
• in what ways do GPs add value? (mechanisms)
• what are the circumstances in which GPs add value? (context)

From the interviews, the team identified 4 underlying theories which could be further tested:

1. GPs’ knowledge about patients will help them to identify problems leading to more prompt solutions;
2. GPs’ knowledge about services will help them to improve service design;
3. GPs’ clinical backgrounds enable a more robust relationship with clinicians within providers;
4. GP and managers have a holistic relationship which enhances commissioning.

Findings

Unsurprisingly, the team found variation in governance structures across different CCGs – as a result, the involvement and engagement of GPs also varies.  The team found some evidence that, where GPs are engaged and involved, making use of their knowledge of patients and services, commissioning decisions are improved.  However, GPs were often reluctant to rely solely on their “anecdotal” knowledge, preferring to combine it with more objective sources of information and with higher level perspectives of commissioning managers.  The team suggest that this is supported by a number of mechanisms, including:  wide representation of GPs in relevant meetings; good preparation for GP representatives attending meetings; provision of quality data and analysis; and GP willingness to engage in person and via emails.

The suggestion that GPs can engage in clinician to clinician discussions was also tested and there was some evidence that the presence of GPs in commissioning discussions can in fact add value.  However, this relies on : preparing GPs well through contextualised information and providing a supportive environment; ensuring those people attending meetings have the authority to make decisions or commit resources; and clear and regular communication to ensure all members are kept informed.

The relationship between GPs and commissioning managers was found to be dependent on mutual trust and clear roles and responsibilities.  However, from the examples given, the effectiveness of these relationships is as much about how they relate to others within the organisation and membership as how they relate to one another.  The research suggests that shared success can help to build mutual trust, with the example given  of one CCG which highlighted the preparation for and outcomes from an assurance meeting with NHS England to show successful joint working.

Commentary

There are some clear recommendations for CCGs to strengthen clinical engagement and empower GPs to bring added value to commissioning, including:

• clarity regarding decision making and governance;
• effective use of GPs’ time enabling them to focus where they can make a real difference;
• clear communication with all GP members to ensure they are kept informed of wider discussions e.g. Health and Wellbeing Boards;
• wide involvement of GP members to ensure it’s not the “usual suspects”;
• high quality information for GPs about local services;
• local consensus on what it means to be a membership organisation;
• communication of achievements to encourage further participation;
• opportunities to shape change programmes, e.g. meaningful outcomes.

Commissioners may wish to consider what proportion of their GPs are currently engaged, formally and informally, and how participation can be broadened to ensure a range of perspectives and to enhance the contribution of GPs. The report makes some practical suggestions, such as empowering GPs to have difficult discussions through robust information, preparation and support.  A key message is to make the best use of GPs’ time.  An insightful example shares very different experiences in two CCGs; one of the CCGs prepared a select committee type meeting with providers which involved preparing GPs to enable them to constructively challenge providers – in contrast, in another CCG, a lack of preparation meant that GPs felt unable to address issues directly in a meeting with providers.

Link

McDermott I et al (2015) Exploring the GP ‘added value’ in commissioning: what works, in what circumstances, and how?  PRUComm.