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Chapter 3 deals with the development and early operation of Clinical Commissioning Groups (CCGs) of GPs. Building upon the context set out in chapter 2, we examine the factors affecting early CCG development, highlighting the complexity of their governance structures, approaches taken to engaging with their members and the development of external relationships with a wide range of new bodies. We found an explicitly ‘bottom up’ approach to policy implementation, with CCGs given considerable lee-way in developing their structures and processes. As a result, the history of previous commissioning structures and arrangements played an important role in the development of each CCG, as did the approach taken by local leaders and by the PCT/ developing NHS England local team. Engagement with local bodies such as Health and Wellbeing Boards and Local Authorities were also significantly affected by local history and geography. We found that the approach taken by NHS England to CCG development, with early freedom to develop as they chose increasingly curtailed by more prescriptive guidance and a complex assurance regime, led to some frustrations for those involved.

Chapter 4 looks at the evidence about clinical engagement in primary care-led commissioning. Extending and strengthening clinical leadership was one of the key elements of the HSCA12. However, this idea was not new, and this chapter reviews the evidence on the role of clinicians in primary care-led commissioning and how this has contributed to the delivery of healthcare services since the early 1990s. It examines the nature of clinical engagement/involvement in the various primary care-led commissioning models that have been introduced into the NHS. Drawing on a review of the literature and our research on Clinical Commissioning Groups the chapter shows how the extent of clinical engagement has varied between the various schemes. GP commissioners have historically been more successful in influencing the work done by GP practices than in making broader changes to services provided by secondary care. The chapter goes on to explore the claims made both by those involved and in official documents about how greater involvement of clinicians in CCGs – and in particular GPs – will enhance commissioning practice. We test this against evidence from our study of CCGs, showing how the engagement and involvement of GPs requires careful attention to detail. Using a realist approach to evaluation, we highlight the contexts and mechanisms associated with successful – and unsuccessful – GP involvement in commissioning.

This chapter explores the cultural embeddedness of medical expertise in three European countries by confronting medical practitioners with an issue that has yet to be integrated into medical practice—problem gambling. Focus-group interviews were conducted with groups of Finnish, Italian, and Polish general practitioners (GPs). Film clips depicting gambling problems served as the interview stimuli. The study shows that the country-specific approaches to the problems in general, and their welfare culture, shape GPs’ views on problematic gambling. The Finnish GPs tend to replicate the Nordic welfare state’s inclusive, all-embracing system logic and they embrace some typical individual traits in the same culture. The Italian context of the Southern European welfare state regime is articulated in the GPs’ discourse about familial relations. The influence of the church in shaping the concept of addiction is also made evident. The profound changes in Polish society initiated deep changes in the perception of social problems, including their individualization: the Polish physicians thus referred to individual and familial contexts of help provision. These findings question a simple medicalization claim, and point towards a more complex picture, where institutional practices will concretely influence how problems are perceived.