Given that membership of a clinical commissioning group (CCG) is fundamental to the operation of a practice, this flags up a number of additional decisions for the partners to make. To avoid any misunderstanding, it is essential for these matters to be identified and a decision-making process agreed in advance.
The decisions fall under three categories: which CCG the practice should join, decision-making as a CCG member and what to do if a partner joins the CCG board.
Which CCG to join
There may be no choice as to which CCG your practice joins, not least because it seems there will be increasing pressure for smaller CCGs to merge in order to be perceived as viable. But if your practice is close to the boundary of two CCGs, there may be a decision to make.
The decision-making clause in your partnership deed should set out the basis of the vote required for this and whether it should require unanimity or a majority. Some sort of majority vote would be preferable, because it is a mandatory requirement to join a CCG, so fence-sitting is not an option.
It is likely (particularly in the case of larger CCGs) that the CCG constitution will delegate most of the decision-making to the board. However, some decision-making will need to be reserved to the members, if only relating to the removal of a board member.
The constitution itself will dictate the voting structure, which could be any of the following:
- Apportioned voting according to list size.
- One vote per practice.
- One vote per GP (which would include salaried GPs and locum GP principals).
If the voting structure is related to the practice and not the individual (that is, either of the first two alternatives above) your partnership deed determines how that vote will be cast.
Partners on the board
You should agree in advance whether as a matter of principle you are prepared to agree to one of the partners taking a place on the CCG board or being a clinical lead, say - and it will be easier to decide the principle in advance of a request from a specific individual to do so.
If your starting point is that it is not appropriate under any circumstances, your deed should make this clear and you should back this up by inserting it as an additional ground for expulsion.
This does not prevent an individual from seeking the partners' consent later, when it may be considered there are good reasons to support the request and to vary the deed accordingly. However, consideration should be given to the hours of commitment required and how this should be treated in terms of 'absence'.
If this is regarded as partnership time, the individual partner's hours of commitment should remain the same and the partnership should invoice the PCT/CCG for the attendance payment and bear the costs of the locum.
Alternatively, if this is treated as the individual partner's time, the partner concerned should reduce their hours to the partnership, resulting in a lower profit share (out of which the partnership could fund the cost of the provision of additional clinical cover, either by appointing a salaried GP/locum or by the other partners making up the time difference in return for the additional share of profits).
This would leave the individual partner to invoice the PCT/CCG and to retain the attendance payment themselves. This might, however, be considered a rash move, given that the board appointment is unlikely to be permanent and once a reduction in hours has been accepted within the partnership, there is no guaranteed return ticket.
Conflicts of interest
It is also important for the partners to appreciate that the duties of the individual partner as a board member should be regarded as completely independent from the interests of the practice. Accordingly, it would be inappropriate for the other partners to agree to the appointment on the basis that they may then be able to exercise influence over the decision-making powers associated with it. A board member must exercise their judgment for the benefit of the CCG as a whole, not for the benefit of their own partnership. Guidance on how to deal with conflicts of interest is expected soon.
It would be apparent therefore that the influence of CCGs as a 'third party' over a practice could lead to tensions within the practice, particularly where a partner is also a board member - and for this reason it is essential to rehearse the problems that might be faced before allowing them to 'evolve', by which time it might be too late to row back.
- Lynne Abbess is a partner at specialist medical solicitors Hempsons, www.hempsons.co.uk