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Douglas Noble on GP commissioning

17 Mar, 11 | by BMJ Group

douglas nobleA few weeks ago I attended a conference for GPs on commissioning in the brave new world of GP consortia, proposed in the recent health bill

The day started with a very upbeat GP seeking to enthuse the audience of about 70 participants with a reverberating war cry: “commissioning! who’s up for it?” One hand shot up like Hermione’s from Harry Potter. A few awkward seconds passed and slowly another hand went up with a turn of the head hoping they weren’t alone. They were. Two out of 70. What a start! 

Various highlights from the day stand out. At one point delegates were split into groups to simulate a commissioning encounter between GP Consortia and Acute Trusts. Amongst other things the scenario involved delivering services for lower cost. With lightening speed our group determined their approach: “What shall we cut?” Someone interjected gently: “What about improving quality in the existing processes of care and reducing costs that way?” “Ooo good idea, we’ll try that too,” was the excited response. 

In the run up to the day there was a last minute change resulting in the workshop on data being dropped. Horrors. Data-free commissioning. Thankfully the email indicated the “data-bit” would be incorporated within another session. I trundled along to this at the end of the day and enjoyed a very competent presentation on the process of commissioning. Two slides went up on data. One on all the different types in the NHS, the other on the vast number of resources to assist with using and understanding it, including the NHS information Centre and NHS Comparators websites. Things were looking up. Then came the next poll: “Who here has ever heard of or used any of these resources?” No hands. Zero out of 35. For a self-selected population of GPs who wanted to come to a commissioning conference this was now starting to get really worrying. 

And that is maybe the bottom line; there is something disturbing about all this sudden change. In essence we are asking a group of doctors with minimal skills in handling service and population level data, negotiating contracts, monitoring performance, and determining health policy, to overnight perform these tasks for large geographical sectors as if they were second nature. It’s not a pathfinder they’ll need; it’s a solar flare. 

Yet, it doesn’t need to be this way. GPs were heavily involved in PCTs on CECs and PECs and numerous other inelegant acronyms. What we need is a repositioning of GPs to be the leading decision-makers ahead of NHS bureaucrats, not a complete restructuring. With this more nuanced approach GP leaders could remove wasteful activities within PCTs, keep the best people with the skills they don’t have, and build joint pathways of care with local hospitals. 

Finally, GPs need to resist the mistake the previous government made by bringing in private consultants at every turn. Instead, for ensuring evidence and population health needs are at the forefront of commissioning, GPs and Public Health doctors need to work together like never before. By sharing their extensive knowledge of patients, populations and quality and safety in healthcare, world class commissioning might even be realised.

Douglas Noble has worked in surgery, emergency medicine, public health and for WHO. From 2006 to 2008 he was clinical adviser to the chief medical officer for England.

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  • http://twitter.com/nontimeo Non Timeo Sed Caveo

    “What we need is a repositioning of GPs to be the leading decision-makers ahead of NHS bureaucrats”.

    Do the NHS bureaucrats get to consult the patients while we make the commissioning decisions?

  • lizzie12s

    I think this encapsulates very clearly the real challenge of transferring the complex task of commissioning to people who to date have generally been on the periphery (don't forget every system is perfectly designed….). As a now redundant NHS manager I am a bit over-sensitive to the connotations of terms like 'bureaucrat' – don't forget many of us have been trying to place GPs and other clinicians at the forefront of commissioning, recognising that a good manager facilitates and supports rather than decides the 'answer'. I know there is a place for us to work effectively together on this, because it does happen. And yes, lets be realistic about clinical capacity and cost effectiveness too.

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