In all the talk of radical health service reforms, one of the factors which has almost been forgotten is the revolutionary shift in mindset required of the NHS manager in primary care.
With the move to full consortium commissioning, comfortable and comforting structures and hierarchies are being dismantled and for many senior and experienced NHS managers there will be an extra novelty to contend with: working for a GP.
But in reality, will managers really be working for GPs? Many believe that consortium commissioning is an unworkable concept because GPs don’t really want these new responsibilities and, even where they do, the majority are simply not up to handling them.
The image they retain is traditional and PCT-shaped; operating centrally and technically accountable to GPs but with NHS managers making much the same decisions in much the same way. In essence their view is that once GPs have realised management isn’t straightforward, normal service will be resumed.
My experience is different. My boss is a GP and the majority of my board is made up of GPs and my job, as chief executive of a consortium of 71 practices, is to support them to make and implement effective decisions.
In 2007, when I moved from my role as a director in an acute trust I had similar misgivings – and I can’t say it’s all been plain sailing. Being managed by a GP was a new experience both for me and my boss. What we found was that we had different strengths and weaknesses. My boss is fantastic at providing clear leadership to GPs and driving change across primary care. Partnership working, at least in the early days, was more of a challenge.
What we have been working on as a board over the last three and half years is finding ways of harnessing strong GP leadership, operating in tandem with effective management. When that happens I think the results are startling.
Having real commissioning decisions genuinely led by GPs has significantly improved the quality of decision making in Northamptonshire. This includes some decisions which primary care trust managers had doggedly but unsuccessfully fought over for many years. Implementing a scheme to ally individual GP practices with individual care homes, thus reducing duplication and improving continuity of care, was one of the GPs’ first. Harmonising the historically unequal provision of post-operative wound care across the county was one of theirs too.
I know some argue GPs simply aren’t tough enough and that we’ll end up with managers continuing to make the really difficult decisions. This is not my experience. Having made a decision to implement a rapid response service for urgent home visits during the day our GPs had no problem in making the difficult decision to decommission the service (from their colleagues) once it had proven ineffective.
It probably doesn’t need saying, but the great thing about clinically led decisions is that they tend to be clinically owned. This vastly improves the likelihood of their being implemented – and in a county-wide consortium covering 650,000 patients with a widely diverse range of needs, successful implementation is everything.
Of course GPs don’t have the time to do the implementation – that’s where the management team comes in. For instance, with engaged GP leadership at every stage we have been able to implement the proactive care scheme across the county and make it the country’s largest case management system for people at risk of emergency admission.
My experience of working for GPs is they expect real product, not simply effective processes. Through proper engagement of member practices commissioning consortia will have available an implementation arm which PCTs never had. The challenge for us as managers is to empower GPs as leaders and enable them to be effective. Working with them – and for them – provides us with the opportunity to achieve the very thing that is at the heart of NHS management: real improvements for patients.