Irrespective of how valid the financial allocation is for each CCG, we as GPs have been given a fixed budget to work within. There are several questions that stem from this, some key ones being is the budget allocation correct, how do we as GPs work within the budget and who is accountable for decision making?
Each CCG has an overall budget allocation based on several factors including deprivation. From that, each member GP practice is allocated an individual budget from which it can spend on unplanned and elective care, prescribing, diagnostics and a few other additional patient services.
Some CCGs have next to no chance breaking even with their commissioning budget
This 'commissioning budget' is separate to the GMS/PMS income which is ultimately used for business running costs. Broadly speaking, very expensive treatments are paid for by NHS England in order to offer a degree of risk share and financial protection to CCGs, however, the 'specialist commissioning' system is unsurprisingly confusing and complex.
From all this lies a huge problem, budget allocation. To cut a long story short, some CCGs, and therefore practices, have next to no chance of breaking even with respect to their commissioning budget, some are on a tightrope whilst other CCGs will have millions to spare come the end of the financial year.
It is intuitively likely that the allocations, which are set centrally, are way off with several major unintended consequences. These include severe stress for NHS staff and more importantly, patients being denied treatment on the basis of rationing and postcode. One can only hope the allocations are set more appropriately next year. At this point it may be sensible to say I'm a commissioner for a CCG with one of the lowest allocations in the country and that my views are my own.
So how do CCGs, GPs and providers work within a tight budget?
So, for those with a clear surplus commissioning budget and a forecast outturn way under allocation, rationing arguably doesn't really come into play; there can be investment in new pathways, services, pilots and innovation.
Conversely, for CCGs with tight allocations, the primary focus is survival. So how do CCGs, GPs and providers work within a tight budget? Let’s be honest, there is waste in the system and that means there is opportunity. Many CCGs will take a multi-pronged approach with the help of their CSUs and focus on projects such as managing variation of activity, reducing waste, pathway redesign, introducing threshold guidelines and referral triaging and contract negotiations with hospitals and other providers.
The trick of course is story telling; to get everyone motivated, on board and involved in achieving the common goal. No involvement, no commitment is the accepted mantra.
Ideally this will all lead to patients taking ownership of their health and disease, and not misusing the NHS, public health coordinating a shift in culture and facilitating change, us GPs referring and ordering tests only where it adds clinical value, and absolutely our hospital providers to recognise they need to change their care model and reduce costs. Of course, a lot of this is happening already and there are plenty of people working incredibly hard to make this happen.
Whatever the decisions we make, our patients and the government will hold us to account. We will be accused by patients of rationing, and if things go wrong, our patients will hold us to account. Sadly, to 'reward' GPs for working several more hours per week and engage in commissioning, manage our budgets and deal with intense patient pressure, the government has significantly reduced our gross and net income.
Like it or not, commissioning is here and we have to deal with it. A finite NHS resource is in it itself an inevitable austerity measure and reasonable as it encourages us as doctors to reduce waste and improve our clinical quality.
Mistakes in allocation of funds between CCGs, making doctors the fall guys and rubbishing them in the press, and screwing pensions to disproportionate levels is not the way to motivate NHS workers and improve patient care. Good luck all!