The concerns expressed by the new chair of the RCGP about the difficulties which GPs might face, in taking on commissioning, are pertinent. There is always a tension between being the advocate for the patient in front of you and for the population behind them. It does seem odd that PCTs have been exhorted to divorce themselves from provision over the last few years and yet, here we are, laying the job of commissioning at the door of a group of clinicians who are wholly inexperienced and untrained to do it. In a recent conversation with some GPs, they told me that they were confident that they could do a better job than the PCT because they would get rid of bureaucracy.  I queried what they thought they could dispense with?

“Individual funding reviews,” came the response.

“How would you make your decisions?” I asked.

“We would just say no,” one GP said, whilst another explained, “It should simply be left to the individual professional and the patient.”

“So what criteria would you use for those decisions?” was my next question. 

I eventually filled the ensuing silence with a short explanation about having a process which was defensible in law and how it might be wise not to confuse that with bureaucracy.

The issues raised by Dr Gerada need to be addressed. GP consortia will need clear processes and defensible decision making, which must be at arm’s length from their role as providers.

GPs are being asked to commit to commissioning.  They are being asked to manage not only the health system, but also themselves. As someone who has migrated from full time general practice to full time management, I cannot concur with her comment that, “If you asked GPs to run a fish-farm they would run it well.” I think some GPs could, once they had spent time and effort learning how to do so.  A major task for consortia will be getting GPs to run general practice well. Although British general practice is currently probably the best primary care in the world, it could be even better.

In Lincolnshire we have been working with local GP leaders and practices, since the publication of the white paper, to begin the transition from PCT-led to GP-led commissioning. We have shared with them the financial challenge which the system faces and what needs to be addressed (the “how” is where their knowledge and experience is invaluable).  What is apparent, again and again, is that to address this problem  the behaviour of clinicians needs to be challenged and that the best placed “managers” for this are other clinicians.  They will need the support of excellent management, managers who are skilled in process improvement, information management, contracting and so on. Unfortunately, GPs need to stop being Gentlemen and learn to be Players in commissioning. My job over the next two years is to stop giving them fish and, instead, to help them fish for themselves.

Martin McShane qualified in 1981 from University College Hospital Medical School. He trained in surgery until 1990 then switched to general practice where he spent over a decade working in a semi-rural practice on the edge of Sheffield. In a fulfilling job, with a great lifestyle, he decided to give it all up and take on a fresh challenge. He entered NHS management, full time, in 2004 as a PCT chief executive after experience in fund holding and chairmanship of both a primary care group and subsequent professional executive committee. Since 2006 he has been director of strategic planning for NHS Lincolnshire, where there are 5,600 miles of road but less than 50 miles of dual carriageway.