“But we are a membership organisation!” the newly appointed GP Chair exclaimed. “Member practices have to have a voice. We need localities to ensure each GP practice is represented in the decision making of the CCG. Each locality needs its own GP leader, the support of a locality manager and we must pay for the time of a representative from each practice to attend locality meetings”.

The Finance Director looked sceptical. He could see the £25 per patient management costs rapidly disappearing into these localities. “But where is the return on investment?” he countered. “If we fund all of that, the costs of five localities could be nearly half a million pounds a year!”

“This is what will make CCGs different to PCTs” hissed the GP Chair. “PCTs had no route into the voice of GPs and GP practices. These localities will be the engine for clinically-led change and redesign, they will ensure we connect commissioning policies to change on the ground, and make sure we can put the decisions we make as a Board into practice. Without them, we won’t deliver anything.”

And so it was that locality groups started off in many CCGs as the great hope for the future, as the symbol of what could be different. But, as is the way of the NHS, the local freedom promised to CCGs did not materialise, and the voice of localities was overtaken by directives from NHS England, the pressures of the 4 hour target, and the need for centralised financial control. Locality GP Chair roles on CCG Governing Bodies were replaced by clinical lead roles for urgent care and planned care and the like. Localities have continued, GP Locality Chairs are still in place, some even have managers, and practices are still paid to attend meetings, but more often than not these meetings now consist of a one way flow of traffic where teams from the CCG present the latest clinical pathway, referral guidance or QIPP plan to the GPs.

What hasn’t changed are the questions from the CCG finance director as to the return on investment of the locality funding. Now the embattled GP Chair simply knows removing it would be just one step too far in trying to maintain any sense of support from member practices.

So what is next for CCG locality groups? As STPs develop, and the system moves to the introduction of integrated care, it is becoming increasingly unclear what is the responsibility of the local GP federation (as a provider, and the “provider partner” within the developing integrated care system) and what is the responsibility of the CCG locality.

There will come a time when all of the functions of the CCG locality – input into clinical pathways, liaison with practices, redesign of services, representing practices in system discussions – will fall to the GP federation, as power shifts from the old system to the new, from commissioners to partnerships of providers. For now, we are in a transition period between the two.

But a transition period is problematic. Already overstretched GPs cannot be in two places at once. Do we want practices to spend the limited time resource they have on existing commissioning localities or on establishing a strong GP provider voice for the future? Realistically we can’t expect them to do both, and doing so simply limits the capacity to do either. The funding we have invested in the localities is no longer in the right place, and would be better situated within the developing federations.

The extent to which CCGs and general practice accelerate this transition may determine the strength and influence of the GP voice in the new system. Because GPs do not have the capacity for double running in a transition period, it is now time to accept the end of the locality within a CCG and to create a new future for them, and maybe allow them to fulfil their initial promise, within (or even as) GP federations.