All of England’s 212 clinical commissioning groups (CCGs) must have a constitution in place before they can become authorised. According to the NHS Commissioning Board (NHSCB), constitutions should outline the CCG’s functions, its decision making processes, how it manages conflicts of interest and explain how it relates to member practices.
However, last year there was some controversy surrounding practices signing up to ‘draconian’ constitutions or inter-practice agreements that placed undue pressure on them to reach targets or face expulsion.
The GPC has warned practices not to sign a constitution before the LMC has signed it off.
The Health and Social Care Act states that CCGs are member organisations accountable to their member practices and this must be reflected in their constitutions.
The GPC says constitutions should make a commitment for the CCG to engage with the LMC as the local statutory representatives of the profession and clearly outline the dispute process by which practices can raise grievances with their CCG.
In its guidance on CCG constitutions, published in May this year, the GPC warned that: ‘A practice should not sign up to their CCG constitution or inter-practice agreement unless they are content with all aspects within either document. If you have concerns, you should immediately seek advice from the LMC or the BMA.’
Some CCGs, such as Rotherham, had to rewrite their constitutions once the NHSCB published its 101-page model constitution in April. The GPC has criticised this model document, saying it is far too detailed to work as a template and completely omits any role or involvement of LMCs.
All practices are contractually required to be a member of one of the 212 CCGs. The GPC says that membership of a CCG will automatically terminate when a practice ceases to hold a contract to provide primary medical services and that a CCG will not be able to expel practices on any other grounds.
GPC deputy chairman Dr Richard Vautrey says: ‘We have provided a check list for all practices to use before they sign a constitution. Practices should also check that the LMC has seen and approved the constitution before doing so.
'They should be particularly vigilant to ensure there is nothing in the constitution related to performance management. That is a role for the NHS Commissioning Board not the CCG.’
Chief executive of Wessex LMCs Dr Nigel Watson says CCGs are now taking inter-practice agreements, some of which sought to expel practices from the CCG if they were not in budget, out of constitutions.
He says those CCGs with inter-practice agreements in their constitutions are not likely to get signed off by the LMCs. ‘Some of the early CCGs were being quite bullish with practices about budgets. We have approximately 11 CCGs in our area and the LMC has signed off three constitutions. Most of our CCG constitutions don’t have inter-practice agreements.
‘The model contract from the NHS Commissioning Board does have some things that concern us such as a clause that we would stay within our budget at a practice level and for the practice to be nice to the CCG and not argue with them. Such clauses aren’t meaningful or helpful,’ Dr Watson adds.
‘The GP’s role isn’t to ration care but to do what is best for the patient. Only approximately 30% of unscheduled care in hospitals comes from GPs. They largely come through Accident and emergency and the ambulance service.’
Dr Watson says that if CCGs are truly going to be membership organisations then their constitutions should contain a clause that allows practices to call a meeting of no confidence in the board.
Director of Slough CCG Dr Gurdip Hear says their constitution ensures that members hold each other to account. ‘Within Slough we, as members, have agreed a way that we will hold each other to account. This framework will be part of our constitution. It gives us clarity and transparency about our joint commitment and responsibilities for making the CCG a success. It includes sharing information on our commissioning performance, peer support and review in addressing any variation in performance backed up by a strong education and training ethos.’
CCGs must have their constitutions ready as part of their authorisation applications. CCGs are set to be authorised by the NHSCB in four waves.
The NHSCB is due to make a decision on the first wave of 35 CCGs in October. The second wave of 70 CCGs submitted their applications at the start of September. The 67 CCGs in wave 3 are due to submit their applications by 1 October and the 40 in wave 4 will submit their applications by 1 November.