It was early 2012 and I was sitting in a hotel, exactly where escapes me. I’d listened to an over-long Powerpoint about the “new best thing about to happen.” The presentation ended. GPs circled, drinking tea and chatting away in hushed tones. Two or three of us approached a group at a table. “Hi, do you fancy making a CCG?” It felt like forming the school rock band. It had the same excitement and a feeling of having no idea where we were going. And so, the journey began.
I’d hate the legacy of CCGs to be a negative one. We achieved so much:
- Public engagement. We moved it on massively. Practice based patient groups fed into CCG PPG groups, and through lay members straight to the CCG board. It started to feel very connected.
- Clinician engagement. I learnt more about local primary care than I ever could have without CCG driven engagement. Names on letterheads turned in to real people, trying to improve patient care as I spent more time inside hospital and community services.
- Breaking down the primary / secondary care divide – GPs sitting down with consultants working together and problem solving. We held a slightly off the wall “service redesign at speed” workshop where GPs and consultants were trying to fix the broken. The informatics team were on hand to provide as-needed data. Ideas ranged from the simple to the slightly crazy. It felt like a cross between Dragon’s Den and Challenge Anika, but we came up with some great initiatives.
- Manager engagement. I’m a clinical manager, so I’m reflecting this, but my non-clinical managerial colleagues tell me it felt different in CCGs. If I’m nervous about the future it probably is this one. It’s not that we won’t have clinicians in managerial roles in the future, it’s that the very close working relationship between non-clinical managers and clinicians may be pushed back a bit – as the new organisations look to widen their clinical, social care and lay input.
- IT integration. The pre-data sharing age seems, well ages ago – but look back just a few years and it was so hard to get just a little integration of IT. We now take it for granted, and our whole mind shift has changed from “why would we” to “why can’t we?” I know there have been multiple catalysts for that, but I think CCGs were a key driver.
So, where do we go from here? Well I hope that Integrated Care Systems (ICS) and Partnerships will build on the best CCGs achieved:
- A broader input from clinicians, moving away from the impression that “it’s up to the GPs.” I think that makes sense. We need more community and secondary care clinicians (not just doctors) – to offer a view of the patient pathway. I don’t think GPs need to fear if the balance is shifted away from being GP dominated. Their voice will be strengthened with the support of others.
- More patient and public involvement – as I mentioned above, I think we made great strides with CCGs, although never quite got to realise the whole vision. Perhaps ICS’ can do that. I’d love to see active and truly autonomous PPGs in every practice offering real leverage right into the ICS.
- Unified budgets and a move away from purchaser provider split. It will be interesting to see how this works out. The money wrangles were so frustrating when working in the CCG. Innovation was stifled by financial constraint. Prevention programmes sometimes take years – think electric cars and respiratory disease. The key thing here that will drive change will be how constrained by budgets ICS’ feel. If the money is very tight it will drive entirely different behaviours than if funding is in abundance. It doesn’t mean you can’t implement change in times of constraint, but it will need imagination, great leadership and a true willingness of all the partners to work together.
- The innovation will be really important. We need to keep empowering people to think of new and slightly radical solutions. Perhaps every ICS will need a department of “Innovation and slightly crazy ideas.” We conceived the “In-reach GP” some years ago, allowing GPs to follow the frailty pathway right inside the hospital. That seemed radical at the time, but I’d really like to turn more things inside out. After the experience of the pandemic, I like the idea of the “Outreach intensive care physician” supporting GPs to help patients make decisions about ceilings of care. I can imagine how hard it is to do that in hospital with a very sick patient at a time of crisis.
- Perhaps the new structures will allow us to shift paradigms, driven by new funding arrangements. I reflect on our whole referral structure, an industry of complex pathways and support structures – the latter often about stopping a referral rather than facilitating it. Why do we refer patients at all? It has sometimes seemed to have been to satisfy the payment-by-results system. If we are taking integration seriously it should be irrelevant if a patient has risen above an arbitrary “referral threshold.” The integrated system should be aware of all patients within that pathway, and of the unmet need of those who are not receiving a sensible level of care. The formal referral could become a thing of the past, replaced by Artificial Intelligence driven identification of individuals with a health need from a unified electronic health record. Perhaps if we really get proactive care services right, we won’t need a Falls Clinic. Perhaps if we really embrace technology in community cardiology, we won’t need a hospital outpatient diagnostic service. It always has to be driven by patient need, or “what would I want for my care”, and no untested idea is a crazy one.
March 2021
The Deer Doctor 