Whether GPs are the right people to lead clinical commissioning is debatable, but if they want to make a successful transition they need a change in approach to their day jobs, says John Deffenbaugh.
It’s not too late to ask this question: are GPs the right people to lead clinical commissioning?
The answer is probably “no”, but they’re now in the frame to take on this role, so it’s essential to appreciate the GP perspective and the challenges they need to address.
Let’s begin with the fact that GPs are small business entrepreneurs. As contractors selling a service they have a keen eye on the bottom line, the use of their limited time, and the quality of what they offer their customers. Theirs is a micro perspective, dealing with patients who come through their door. This is largely about one-to-one customer service, dealing with the person in front of them.
GPs have to be operationally effective and, because of targets and their payment mechanism, they need to align this patient contact with their potential income. There is a strong task process driving this transaction and their mindset. Not to mention a somewhat maverick and individualistic streak.
Commissioning could not be more different. Rather than a small micro business focus they have to take a big picture, macro perspective. Instead of individual patients, they’re dealing with a complex system, beyond the comprehension of many already operating at that level. Rather than tasks, GPs will need to think about the inter-related processes of flow and dependency within the system. This is oil and vinegar.
Yet they are being asked to take on a £60bn commissioning role across England. Their challenge is to move their mindset into commissioning. If GPs make this transition then they’ll be as well placed as their predecessors who, over the past 20 years did not, frankly, do a very effective job.
It is within the grasp of many GPs to make this transition, but there are three inter-related challenges they must face.
First is to adopt a strategic perspective. They will need to raise their eyes and look at the whole system they either control or can influence. This is not just within their NHS budget, but beyond. Take, for example, mental health. The costs the NHS incurs are one thing, but the wider human costs and output losses can be over four times this amount. Estimates of the annual total cost of mental illness range from £70bn-£90bn.
Taking a long-term, total cost view will enable GPs to make a step change in service design and delivery to fix a priority area that has been a Cinderella service for way too long. After all, they see these problems first hand in the disproportionate number of their patients with mental health issues, so it is only logical to compound this up to a system perspective.
Second, GPs will need to engage, influence and motivate a wide range of stakeholders. There are the practices and partners in their own clinical commissioning group, with a focus on improving quality, reducing variation, and maximising spend. Tackling the outliers will be paramount. Then there are the providers they will have to convince to change their ways. This won’t be easy, especially those foundation trusts that think they rule the roost, and may be regarded as “too big to fail”.
There is also the engagement of patients, communities and the general public. This is where GPs can really score. They’re the closest to the customer, and a realistic explanation about the pros and cons of certain services – be they community hospitals, maternity services or A&E – will go a long way to stripping away the veneer of ignorance about quality, safety and cost.
The third challenge is to prioritise and achieve service change. It’s the only game in town to deliver quality, innovation, productivity and prevention, but so far it’s just been about tinkering at the edges. The NHS is still driven by acute illness, so changing the balance is like turning the a tanker. However, GPs must make this work. We haven’t even begun to explore telemedicine or other technologies. As trusted professionals, GPs can unhook the public from its obsession with bricks and mortar.
GPs have it in their grasp to make this paradigm shift. Reliance on commissioning support is not the answer, since that becomes a crutch to lean on. Rather it is about enabling GPs who want to be commissioners to grow into the role. This calls for on-the-job training, and bringing their entrepreneurial skills to the new role.
GPs can lead clinical commissioning groups, but if they don’t make this transition, then, to paraphrase George Lucas, the Empire will strike back.