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.