Martin McShane: Quis custodiet ipsos custodes?

Martin McShaneThere are about 38,000 primary care contracts. They are worth over £12 billion. All of them are going to be the responsibility of the National Commissioning Board. By 2013 every PCT cluster will have had to scrutinise every contract, blow the dust off the ones that no one has looked at in years, and make sure they are fit for purpose. Then begins the task of creating greater convergence as to how these contracts are managed.

The attention which PCTs have given to primary care contract management has been varied, to put it politely. Bringing all of the contracts under one roof will create an unprecedented strategic oversight. This transformation is a piece of work which, ultimately, will require significant resources to be deployed by the NHS Commissioning Board. It has the potential to be used to build on the best and challenge the worst in primary care. It will need the NHS Commissioning Board to have a strategy for primary care. The board will need to track the impact good quality primary care has across the system and how to foster and incentivise it across the country. In addition it will have to have a clear process to manage poor performance, as well as entry and exit of providers. Some of this exists in some parts of the country. None of it exists everywhere in England.

So what does this mean for Clinical Commissioning Groups (CCGs)? It gives the NHS commissioning board a lever on primary care. However, given the evidence of the importance of the influence of primary care in health systems, CCGs will want to influence how that lever is used. Also, experience of the standard national acute contract would suggest that any such contract management requires local contextualisation. For this to work well will require strong relationships between the NHS commissioning board and CCGs. They will need a common vision, purpose, and alignment of goals. The leaders of CCGs will need to be able to look into the mirror held up to primary care and not flinch. Clinical commissioners will need to have an internal locus of control and take responsibility for developing and improving primary care alongside the NHS Commissioning Board. If they don’t, then experience of contract management from the centre is not encouraging. Influencing and shaping this critical relationship with the NHS Commissioning Board will be vital for CCGs.

The exposure of general practice to a more standardised form of contract management will create a thread of accountability intertwined with commissioning that will have the potential to be a check and balance on the membership of each and every CCG. This will require a nuanced and quite sophisticated partnership between CCGs and the NHS Commissioning Board if the, potentially massive, benefits are to be realised.

As this all needs to be in place by April 2013, can I make a plea? If you see some harassed and tired PCT primary contracting people in the next few months – be kind to them!

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.