1. General Practitioners (GPs) in the UK operate private businesses that contract independently with the National Health Service to provide general medical services. 2. Over time, GPs have become salaried professionals for the NHS, undergone mandatory training programs, and taken on various roles in commissioning local health services through agreements with primary care organizations. 3. Currently in England, clinical commissioning groups (CCGs) made up of general practices are responsible for commissioning the majority of local NHS services, including elective hospital care, community health services, and mental health services.

1. Gestió de l’atenció Hospitalària al Regne Unit (APUNTS)
http://www.nhsemployers.org/HealthWhitePaper/Pages/HealthWhitePaper.aspx
General medical services is the name used in the United Kingdom to describe the
medical services provided by General Practitioners (GPs or family doctors) who, in
effect, run private businesses independently contracting with the National Health
Service.
Proposals to make GPs salaried professionals were rejected by the profession in 1948
The defining feature of PMS agreements is their local nature. Unlike GMS contracts,
they are negotiated between the PCO and the practice, and are not subject to direct
national negotiations between the Department of Health and the General Practitioners
Committee of the BMA. Nevertheless, the national GMS contract, which came into
force on 1 April 2004, had a strong impact on PMS policy and on the contents of
PMS agreements.
1960s – Contractual improvements
In 1966 a new contract improved pay and conditions for GPs, instituting a maximum
list size of 2,000 patients and providing resources for professional education,
improvement of premises and hiring of support staff.
1970s – Professionalisation
The creation of the Royal College of General Practitioners, in 1972, gave GPs a
official representative body for the first time.
After years of concern about the adequacy of GP training, from 1976 three-year
postgraduate training programmes became mandatory.
1990sGP fundholding (VOLUNTARI) allowed GPs to take on responsibilities for
commissioning services on their patients’ behalf, creating an incentive for GPs to
become more involved with the wider health system.
Before this, local health authorities organised both the planning and the delivery of
services for their patients. In 1991 the Conservative government split this function by
creating 'purchasers' and 'providers' in the local health system (NHS and Community
Care Act 1990). It created two models of commissioning – one based on health
authorities, and the other based on general practice.
Under GP fundholding GPs held real budgets with which they purchased primarily
non-urgent elective and community care for patients; they had the right to keep any
savings and had the freedom to deliver new services. The aim was to give GPs a
financial incentive to manage costs and to apply some competitive pressure to
hospital providers. Some GP practices came together in consortia, creating larger
organisations to pool financial risk and share resources.
From 1994 the total purchasing pilot scheme (TPP) allowed general practices – either
individually or in groups – to commission all services for their patients, though most
were highly selective in what they chose to purchase
Dr
Josep
Vidal-­‐Alaball
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2. Many practices joined, covering just over 40% of the population and controlling
around 8% of the NHS budget for hospital and community health services.
1997 New Labour under Tony Blair is elected with a promise to scrap the
internal market and GP fundholding, and to replace competition with
collaboration.
2000s –
After the NHS staggers under the pressures of a winter hospital crisis,
Labour responds with an ambitious "NHS plan" and massively increases
investment
Primary care trusts are created to purchase healthcare on behalf of GPs.
It re-adopts the principles of competition
Quality and Outcomes Framework (QOF)
The 2004 GP contract represented a new relationship between GPs and the NHS,
putting an increased emphasis on performance-related pay, as measured by the QOF.
Competition in primary care was encouraged through enabling patient choice of
general practice, scrapping practice boundaries, and introducing independent- sector
competition through ‘any willing provider’ contracts.
2013 Creation in England of NHS Commissioning Board and Clinical
Commissioning Groups to replace SHA's and PCT's.
DADES:
In 2009, there were 32,111 full-time equivalent (FTE) GPs and 72,153 FTE practice
staff working in general practice in England across 8,228 practices (not including GP
registrars or GP retainers).
In 2008 there were 300 million general practice consultations, 62 per cent of which
were undertaken by GPs.
GPs made 9.3 million referrals to secondary care, suggesting that around one in 20
GP consultations results in a referral to secondary care. That means 19 out of 20 GP
consultations, plus consultations with other general practice staff, were resolved
within general practice by health professionals with generalist skills.
Structure of GP Pay - NHS 85%, Private 15%
NHS
Basic work
20%
50%
15%
Basic Practice Allowance
Capitation Payments
Item of Service (imms, maternity, minor ops,
5%
Targets – Smears and childhood vaccinations
contraception)
Dr
Josep
Vidal-­‐Alaball
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3. 10%
Miscellaneous
(training
grant,
premises,
committees)
Staff Reimbursements – 75-80% of salaries covered by staff budget
Private
Medicals, reports, drug trials
Primary care capitation payments in the UK http://www.biomedcentral.com/14726963/10/156
Spending on GP services has dropped over the past ten years, while investment in
hospitals has risen sharply, showing the Department of Health’s plans to shift more
care into the community and cut costs are in reverse.
The report from the Nuffield Trust reveals spending on GP services has dipped by
0.2% a year over the last five years, with no additional investment into general
practice since 2005.
This compares with spending on secondary care jumping 40.1% over the same period
- an equivalent of an average increase of over 5% a year.
http://www.pulsetoday.co.uk/your-practice/practice-topics/practice-income/gpfunding-cut-while-hospital-spending-increasessharply/20002142.article#.UnmD6ZGztzs
Clinical commissioning:
What can we learn from previous commissioning models?
http://www.kingsfund.org.uk/topics/nhs-reform/white-paper/gp-commissioning
In England, commissioning was primarily carried out by 152 primary care trusts
(PCTs), which in 2009/10 received £80 billion (more than 80 per cent of the NHS
budget) to purchase care for an average population per PCT of 300,000.
A total of 211 CCGs will, from 1 April 2013, be responsible for £65 billion of the £95
billion NHS commissioning budget http://www.england.nhs.uk/ccg-details/
http://www.rcn.org.uk/__data/assets/pdf_file/0019/502714/7.13_RCN_Fact_sheet_on
_Clinical_commissioning_groups_April_2013.pdf
Clinical Commissioning Boards: autorització, regulació CCG. National body, which
has been given a formal mandate to oversee the commissioning of health services in
England
MEMBERSHIP: CCG's governing body includes GPs, hospital doctors, a nurse and
lay members representing the public.
http://www.kingsfund.org.uk/press/press-releases/conflicting-opinions-among-ccgleaders-and-gp-members-over-who-owns-new
They are independent statutory bodies, led by their members: the GP practices in their
area
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Josep
Vidal-­‐Alaball
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4. All general practices will be required to become members of a clinical commissioning
group that will hold real budgets and commission the majority of NHS services for
their patients (including elective hospital care, rehabilitative care, urgent and
emergency care, most community health services, and mental health and learning
disability services). A new NHS Commissioning Board (NCB) will calculate practicelevel budgets and allocate these to CCGs
http://www.kingsfund.org.uk/publications/clinical-commissioning-groups
1. First, they are responsible for commissioning secondary and community care
services for their local population.
2. Second, they have a role in supporting quality improvement in general
practice.
Clinical Commissioning Groups are groups of General Practices that work together to
plan and design local health services in England. They do this by 'commissioning' or
buying health and care services including:
•
•
•
•
•
Planned hospital care
Urgent and emergency care
Rehabilitation care
Community health services
Mental health and learning disability services
These two roles are closely connected – it is not possible to commission secondary
care effectively without also considering the way patients are supported in primary
care
Thus we can expect that many CCGs will look to encourage the development of new
models of primary care to support their plans to shift care out of hospital and enable
better coordinated care.
It is, however, still unclear as to how CCGs will be able to exert influence over the
services delivered by the practices that are members of the CCG – CCGs do not
contract with practices for their core services (that is the role of NHS England) and
they do not have direct legal authority over the clinical behaviour of practices
As well as overseeing Clinical Commissioning Groups, NHS England commissions
some services itself. These are:
•
•
•
•
General Practice
Pharmacy
Dentists
Specialist services (i.e. those required by a limited number of people)
Under the terms of the regulations, commissioners are expected to consider whether
more competition and choice might improve quality, although the same regulations
also allow commissioners to award a contract without competition if the
commissioner is satisfied that only one provider is capable of delivering that service.
Dr
Josep
Vidal-­‐Alaball
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5. Commissioning support services. To carry out some of the commissioning functions
for them across local authority boundaries. However, final commissioning decisions
must be made by the CCG and cannot be delegated.
OPORTUNITAT
CCGs have a real opportunity to get clinical expertise into the heart of decisionmaking
Identifying population needs and designing the care pathways that can reduce
costs and improve patient care locally. From day one it will be critical for new
consortia to identify the models of care and prevention that are needed most to
provide better, seamless care throughout the patient journey. Clinical commissioning
groups will need strong clinical engagement and innovation to develop preventative
care pathways to address health needs of those most at risk. This will require, for
example, new models for managing long-term conditions, supporting the delivery of
self-care and working collaboratively with patients to allow them to make full use of
assistive technology.
Engaging the right organisations and stakeholders that will help deliver
consortia’s vision to improve health outcomes for the local population. Clinical
commissioning groups will need to build the right multi-professional relationships
Dr
Josep
Vidal-­‐Alaball
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6. across primary, secondary, social care providers, local authorities and undertake
strong public consultation exercises, to deliver the service changes they wish to see.
In bringing about this change CCGs will have to enter a dialogue with their local
communities. Trust and integrity will underpin this dialogue and perhaps this is
where the clinicians of the new CCGs may have an advantage, in the eyes of the
public, compared to the previous primary care trust managers
TRANSPARENCY: CCGs are public bodies and are required to hold their meetings
in public and publish minutes. They also have to publish details of contracts with
health services.
EXEMPLE: SPECSAVERS
http://www.gponline.com/Promotional_Feature/article/1115939/commissioning-nhshearing-services-promotional-feature/
http://bcove.me/rejmwn8u
Network of over 440 Hearing Centres across the UK
We have a proven record of successfully working with the NHS over many years,
providing eye tests, diabetic retinal screening, hearing assessments and digital hearing
aids to a number of Primary Care Trusts across the UK.
For CCG’s and GPs looking to commission Adult Hearing Services, we can bring
hearing care closer to your patients' homes. With appointment times to suit their
lifestyle, Specsavers can offer a comprehensive and cost-effective service, with
hearing assessments within two weeks of referral, and hearing aids supplied and fitted
to NHS patients within five weeks of referral. But it doesn't stop there; our service
ensures up to three-years' patient aftercare too.
GPs face pressure from patients after Specsavers markets its NHS audiology
service
The leading commercial eyecare provider Specsavers has been criticised for directly
marketing its NHS funded hearing care services to patients, amid fear of a surge in
demand that could destabilise NHS finances
The company has secured more than 30 contracts to provide community audiology
services across England
Specsavers has sent out leaflets to patients, featuring the NHS logo, urging them to
ask their GP to refer them to Specsavers for free hearing tests, free digital hearing
aids, and free aftercare. The company has also placed advertisements for its NHS
services in newspapers and on buses.
Dr
Josep
Vidal-­‐Alaball
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7. GP commissioners are concerned that the marketing drive may stimulate unnecessary
demand and hamper their efforts to keep increasingly tight NHS finances under
control.
Ways of working that support CCGs and NHS England to secure high
quality care for all, now and for future generations
http://www.england.nhs.uk/wp-content/uploads/2013/07/ways-of-working.pdf
Problems CCG
No experience: http://www.england.nhs.uk/resources/resources-­‐for-­‐ccgs/
http://www.england.nhs.uk/wp-­‐content/uploads/2012/07/comm-­‐maternity-­‐
services.pdf
http://www.hsj.co.uk/home/commissioning/the-challenges-facing-ccgleaders/5057808.article#.UoK7JJH9Nzs
Managers from the defunct primary care trusts are being rehired to lead the new
clinical commissioning groups made up of GPs. Of 81 CCGs to have made
appointments, 50 have chosen a manager.
The act has had many opponents and should Labour win the next election in 2015 it
has said it will transfer the commissioning of healthcare to local councils. So the new
CCGs face the prospect that their lifespan could turn out to be shorter than their
gestation.
“the more it changes, the more it’s the same thing”
When we consider the recent reorganisation, we have to remember there is a
difference between change and improvement; all improvement is change but not all
change is an improvement. Time will tell whether we are on a path to improvement or
merely change.
Although the changes on 1 April brought about a shift of power from managers to
clinicians, the next more radical shift needs to be from clinicians to the public.
OTHER:
A day in the life of ... a CCG chief officer
http://www.theguardian.com/healthcare-network/2012/dec/07/ccg-officer-day-in-life
Key statistics on the NHS
http://www.nhsconfed.org/priorities/political-engagement/Pages/NHS-statistics.aspx
NHS Nene Clinical Commissioning Group http://www.neneccg.nhs.uk
Dr
Josep
Vidal-­‐Alaball
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