One of the key elements of the Health and Social Care Act 2012 (HSCA 2012) was the transfer of responsibility for commissioning healthcare services from managerially led Primary Care Trusts (PCTs) to newly established Clinical Commissioning Groups (CCGs), led by General Practitioners (family doctors or primary care physicians, generally known as GPs). The 2010 White paper, ‘Equity and Excellence’ argued that:
Commissioning by GP consortia [now known as CCGs] will mean that the redesign of patient pathways and local services is always clinically led and based on more effective dialogue and partnership with hospital specialists. It will bring together responsibility for clinical decisions and for the financial consequences of these decisions (Department of Health, 2010, paragraph 4.4).
The document goes on to acknowledge that this approach is not wholly new, arguing that, ‘commissioning never became a real transfer of responsibility. So we will learn from the past, and offer a clear way forward for GP consortia’ (Department of Health, 2010, paragraph 4.5).
In this chapter we examine that history, and explore what can be learnt from previous attempts to involve GPs in commissioning care. We will then apply that learning to the provisions of the HSCA 2012, highlighting the correspondences and discontinuities between what we know from history and what was proposed. We will then go on to present evidence from our research on CCGs, exploring what happened in practice when CCGs were established. Finally, we will discuss the continuing evolution of health policy in the UK in the light of both historical evidence and our current findings. Throughout this chapter, the focus is upon GP involvement in commissioning, rather than the wider concern of clinician involvement. This is because the explicit goal of the HSCA 2012 was to bring GPs back into the forefront of commissioning.
Clinically led commissioning: a brief history
This and the subsequent section draw on a comprehensive literature review carried out between 2011 and 2014 (Miller et al, 2012; Miller et al, 2015), where all the relevant references can be found. Clinical involvement in the commissioning of healthcare services started with the introduction of the quasi-market into the NHS in 1991. The function of purchasing services was separated out from their provision, with Health Authorities established as purchasing bodies, responsible for assessing population needs and purchasing care from semiautonomous NHS Trusts.