GP commissioning consortia will not be created by guidance notes from the Department of Health. Nor will they be formed by primary care trusts and strategic health authorities suggesting the necessary population size for efficient commissioning.
Consortia will evolve through the hard work of enthusiastic GPs developing their leadership skills, mentoring their colleagues and drawing them along.
Commissioning localities have only been formed successfully in Cumbria over the past two years due to hundreds of conversations taking place, mainly between GP leaders and their colleagues, about how it could improve patient outcomes. This process takes time, leadership and effort.
There is a danger that the government, PCTs and SHAs will want to shortcut this development by suggesting necessary organisational structures and processes before GPs have talked through what commissioning might mean for their own patients and work.
Along with the majority of NHS managers, I have spent my working life in large organisations. I work in buildings with several floors of open plan offices. That is our experience of NHS commissioning to date. It is common sense that PCTs and SHAs believe this is what commissioning will look like when it is run by GP consortia.
Conversely, most GPs have spent their working lives delivering care and helping to run very small organisations. Their work, and therefore their vision, is very focused. For them, the idea of needing a floor full of managers and staff to carry out commissioning is at best weird and at worse scandalous.
NHS Cumbria chief executive Sue Page has spent most of her time running the PCT by working with GPs within their own organisations. Commissioning consortia have developed from conversations that took place within practices. They have been built from small businesses upwards, not from large organisations downwards.
Consortia will gain their GPs’ allegiance if three things happen at once. First, you need a number of GPs who really want to develop commissioning and lead that process. Very few GPs simply know how to lead a commissioning organisation. They need some time and effort describing how it might affect their practice and those of other GPs. This will begin to separate them from nearly all of their colleagues who can’t understand why any GP would want to do this. One of the local leads in Cumbria was described as “crazy” by a colleague because he wanted to lead commissioning.
GP leaders need to keep practising, but they also need to recognise what leadership means. One leader in Cumbria asked me if he would be responsible for improving the inefficient practices of his fellow GPs. Peer to peer review and management is a big step in developing consortia. When told this would be his job, he said very quietly: “I could do that.”
Second, these leaders need to have hundreds of conversations with the other GPs about what commissioning might mean. These start with a puzzled audience, as many are unsure. The leaders must give their colleagues the space to think through what is important to them and about how much better referral could be. In one place our problem is mental health, in another it’s diabetes, and in most it’s not getting timely information about patients when they are referred. Most GPs feel that better commissioning will mean better and more controlled referrals.
This takes time. Shortcuts will leave GPs feeling pushed around.
Third, a transfer of real power and resources has to happen alongside this development work. GPs will only realise what can be achieved by actually doing it. Practical people learn by doing things for real. A simulation helped a lot in Cumbria, but the consortia have been successful because, over time, they have started to take real power. This policy will not work if the change is expected to happen across the country in one day.
Does any of this matter to outcomes? Comparing month one in 2010-11 with the same month in 2008-09 saw a drop of 2 per cent in non-elective admissions in Cumbria compared to an 8.9 per cent rise in the rest of England in the same period. Between 2008-09 and 2009-10 A&E attendances decreased by 13 per cent in Cumbria but rose by 4.7 per cent in the rest of England. Comparing month one in 2010-11 with the same month in 2008-09, there was a 5 per cent decrease in first outpatient appointments in Cumbria compared with a 6 per cent increase in England overall.
These are the objects of policy for our NHS. Take time developing the transfer of real responsibility to GPs, allow them to find their own way and the outcomes will follow.