The original idea, widely supported in principle, was that GPs should be put in a stronger position to act as the agents of patients, enabling their choices and supporting the design of care services that met their needs. Clinical commissioning groups as an alternative to primary care trusts became the preferred route to formally give family doctors the necessary leadership powers.
However, just this week, the British Medical Association’s committee have expressed how their initial enthusiasm for the proposal has turned to active opposition. The reality of clinical commissioning groups, they argue, is that they will severely constrain and disempower GPs by centralising decision-making to the NHS Commissioning Board while undermining their relationship with patients.
How did it come to this? The answer lies in a misreading of history, a lack of understanding of what motivates GPs, and a subsequent ill-advised attempt to force statutory commissioning responsibilities on GPs. When the policy of GP commissioning was first announced, evidence from the 1990s era of GP fundholding was invoked to argue that GP commissioning would bring significant benefits to patients. However, this misrepresented the strength of the evidence since the impact of GP fundholding was very much at the margins of today’s greater commissioning challenges. Only a small percentage of innovative GPs really used purchasing freedoms effectively. More importantly, the scheme was voluntary and most GPs were motivated by the opportunities to provide services locally rather than by commissioning itself.
More recent evidence from practice-based commissioning highlighted the significant mismatch between the aspirations of GPs wishing (in the main) to provide new services and PCTs’ focus on delivering care to the wider population. For many GPs, practice-based commissioning turned out to be frustratingly bureaucratic, unprofessional and slow, without the promised freedom to purchase services directly. For those in PCTs, their unwillingness to ‘let go’ was linked to their frustration that practice-based commissioners focused on small-scale investments rather than the bigger picture.
With no direct provider benefits for participation in PCTs, many GPs are puzzled by the willingness of their colleagues to take on key commissioning roles. In a study I undertook in the early 2000s, some GPs recognised their commissioning colleagues as ‘visionaries’ keen to make a difference to the lives of local people. However, most others were variously labelled ‘megalomaniacs’ (wanting power for the sake of it); ‘put upon’ (doing it because no-one else volunteered); ‘opportunists’ (to gain funding for new services); or ‘going through a middle-aged crisis’ (fed up with the general practice and needing a new challenge). None were viewed as having the core skill sets required to commission effectively, and many GPs seemingly mistrusted or lacked respect for their colleagues in these new positions.
When considering how to motivate GPs to take part in commissioning, two key lessons from history emerge. First, the core motivation is for GPs to act as providers. This means their involvement is potentially a good idea for promoting ideas on innovation in primary and community care delivery, but far less good for dealing with wider commissioning responsibilities. Second, the approach succeeds best when budgets are truly devolved, with the power and freedom to both purchase and provide services.
As we argued in our original response to the health White Paper, a better course of action than the current clinical commissioning group arrangement would be to allow multispecialty provider groups or care partnerships – perhaps built around federations of practices – to take on more financial responsibility and accountability without full statutory responsibility for commissioning. This would encourage them to innovate in providing extended primary care-based services, as well as to manage the resources their patients use in other settings.
Such an approach needs a strategic commissioner, rather than a local clinical commissioning group, to contract for the risk-sharing arrangements and to hold the provider groups to account for performance and ensure they manage conflicts of interest sufficiently. Incentives would not be linked to the ability to make budget savings, but for hitting key markers in terms of engaging local people in decisions, improving patient experiences and quality of care, and achieving better care outcomes cost-effectively.
It is highly unlikely that the Health and Social Care Bill will be overturned, and in any case the development of clinical commissioning groups and PCT clusters has already reached a stage where it would be counter-productive to change tack. Rather, this emerging commissioning infrastructure needs to evolve so that it can best support what is needed to motivate, influence and invest in primary and community care-based developments that meet the needs of individuals and local populations. These new arrangements need to evolve at speed and will require intensive support in the process.
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