Should GPs be given statutory commissioning roles?

Many aspects of the Health and Social Care Bill have given rise to heated debate, but one of the most controversial has been the question of whether GPs should have formal statutory responsibility for commissioning.

The original idea, widely supported in principle, was that GPs should be put in a stronger position to act as the agents of patients, enabling their choices and supporting the design of care services that met their needs. Clinical commissioning groups as an alternative to primary care trusts (PCTs) became the preferred route to formally give family doctors the necessary leadership powers.

However, just this week, the British Medical Association’s committee have expressed how their initial enthusiasm for the proposal has turned to active opposition. The reality of clinical commissioning groups, they argue, is that they will severely constrain and disempower GPs by centralising decision-making to the NHS Commissioning Board while undermining their relationship with patients.

How did it come to this? The answer lies in a misreading of history, a lack of understanding of what motivates GPs, and a subsequent ill-advised attempt to force statutory commissioning responsibilities on GPs. When the policy of GP commissioning was first announced, evidence from the 1990s era of GP fundholding was invoked to argue that GP commissioning would bring significant benefits to patients. However, this misrepresented the strength of the evidence since the impact of GP fundholding was very much at the margins of today's greater commissioning challenges. Only a small percentage of innovative GPs really used purchasing freedoms effectively. More importantly, the scheme was voluntary and most GPs were motivated by the opportunities to provide services locally rather than by commissioning itself.

More recent evidence from practice-based commissioning highlighted the significant mismatch between the aspirations of GPs wishing (in the main) to provide new services and PCTs’ focus on delivering care to the wider population. For many GPs, practice-based commissioning turned out to be frustratingly bureaucratic, unprofessional and slow, without the promised freedom to purchase services directly. For those in PCTs, their unwillingness to 'let go' was linked to their frustration that practice-based commissioners focused on small-scale investments rather than the bigger picture.

With no direct provider benefits for participation in PCTs, many GPs are puzzled by the willingness of their colleagues to take on key commissioning roles. In a study I undertook in the early 2000s, some GPs recognised their commissioning colleagues as 'visionaries' keen to make a difference to the lives of local people. However, most others were variously labelled 'megalomaniacs' (wanting power for the sake of it); 'put upon' (doing it because no-one else volunteered); 'opportunists' (to gain funding for new services); or ‘going through a middle-aged crisis' (fed up with the general practice and needing a new challenge). None were viewed as having the core skill sets required to commission effectively, and many GPs seemingly mistrusted or lacked respect for their colleagues in these new positions.

When considering how to motivate GPs to take part in commissioning, two key lessons from history emerge. First, the core motivation is for GPs to act as providers. This means their involvement is potentially a good idea for promoting ideas on innovation in primary and community care delivery, but far less good for dealing with wider commissioning responsibilities. Second, the approach succeeds best when budgets are truly devolved, with the power and freedom to both purchase and provide services.

As we argued in our original response to the health White Paper, a better course of action than the current clinical commissioning group arrangement would be to allow multispecialty provider groups or care partnerships – perhaps built around federations of practices – to take on more financial responsibility and accountability without full statutory responsibility for commissioning. This would encourage them to innovate in providing extended primary care-based services, as well as to manage the resources their patients use in other settings.

Such an approach needs a strategic commissioner, rather than a local clinical commissioning group, to contract for the risk-sharing arrangements and to hold the provider groups to account for performance and ensure they manage conflicts of interest sufficiently. Incentives would not be linked to the ability to make budget savings, but for hitting key markers in terms of engaging local people in decisions, improving patient experiences and quality of care, and achieving better care outcomes cost-effectively.

It is highly unlikely that the Health and Social Care Bill will be overturned, and in any case the development of clinical commissioning groups and PCT clusters has already reached a stage where it would be counter-productive to change tack. Rather, this emerging commissioning infrastructure needs to evolve so that it can best support what is needed to motivate, influence and invest in primary and community care-based developments that meet the needs of individuals and local populations. These new arrangements need to evolve at speed and will require intensive support in the process.

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Comments

#1098 John Foster
Principal research fellow
University of Greenwich

I am not a gp but have recently evaluated a community engagement event re commissioning role. As an independent researcher it was abundantly clear to me that gps require an enormous input from somewhere to develop the skills required to engage the wider public. As this blog states gps are often excellent in expanding the services of their own practices but less so at engaging a wider public. Totally agree

#1099 Nosap Ience

What I still can't get my head around is how we can give any responsibility at all to GPs who are effectively private subcontractors to the NHS. They aren't even members of NHS staff!

So what the hell, if we can give commissioning to GPs who are not qualified to do it, why don't we just go the whole hog and give it all to Tesco's. Because let's face it, if this bill becomes law it won't be long before the majority of GPs will be wearing blue checked shirts and sitting under a banner thy says "every little helps".

Don't laugh, when a Tesco's opens 40% of the local competition goes bust.

#1100 Alex

1. Thanks for this. Very interesting.

2. What, exactly, do you mean by “engaging local people in decisions”? For example, how ‘engaged’ should they be? And which “local people”?

#1101 Andrew Harding
Research Associate
Bournemouth University

Alex, in the mid to late 90s The King's Fund and IPPR did some work on citizens' juries. To me, in principle at least, these structures would seem to be able to run alongside, or as part of, CCGs. NICE also ran one - all with relative levels of success.

Accountability has always been a big issue in the NHS, and particularly around commissioning. There seems a synergy between local engagement and increasing accountability.

#1102 Alex

1. Andrew, thanks for the response.

2. I really worry that so much of this talk about ‘engagement’ is, well, talk. Empty rhetoric. I’m not only referring to ‘engagement’ for the NHS and health services, either. It’s an issue across public services.

#1103 Mary E Hoult

I thought GPs had a Commissioning Role on the first PCGs set up in 2003/6 then on the various PCT boards and now on the new CCGs that's nearly 10 years !! the only difference is they will not be protected by the SHOs and PCTs they will stand alone with only the NHS Commissioning Board as their only bed fellows.

#1104 John Chater

My understanding is that responsibility for commissioning will reside with the NHS Commissioning Board, which will directly provide specialist commissioning services and, through CCGs, be responsible for the provision of local commissioning services by agreeing commissioning plans (which will be measured against the commissioning outcomes framework and the joint strategic needs strategy produced by the local authority). CCGs (not just GPs) will commission under licence of the NHS Board and not as separately constituted statutory bodies.

As for your suggestion to create 'multispecialty provider groups or care partnerships – perhaps built around federations of practices', well, it is difficult to see how such an arrangement would provide any more stability and certainty than CCGs, as both would be locally constituted, mercurial in operation and subject to easy change.

I suspect we will see more of the same though, no matter what happens; namely, the same 'fighter pilot' GPs who are always pushing to the front will be at the front, looking to maximise commercial or political opportunities. I would call them neither 'visionaries' nor 'megalomaniacs', but rather opportunistic – exactly what one would anticipate in a profession dominated by alpha male/female personalities. After all, as has been pointed out already, they are first and foremost in business for themselves. The rest of GPs will continue as before, providing a service to patients and quietly (or not so quietly) griping about the ambitions of their more flamboyant colleagues.

#1105 Mary E Hoult
community volunteer

I agree with the above comment about more of the same. I have a group photograph taken of the board /PCT responsible for hospital re design period 2003/6 which is exactly the same group as our the New PCG Consortium the only difference is I 'm not on the new group. I was the Community Health Council lay member for the group.

#1106 Celia Davies

Nick
It is refreshing to see the kind of reflection on research results that you produce here. The misuses of what what can never be totally decisive evidence in this kind of field seem to be increasing - fueled perhaps by cuts in staffing at DH and beyond. I would like to encourage the Kings Fund to think of making available research syntheses alongside blogs like this. It would do a real service in improving the quality of serious debate on finding a way for the NHS in its next few difficult years.

#1107 Nick Goodwin
Senior Fellow
The King's Fund

Celia

Thanks for your comments - agree and a good idea.

Having researched and observed GP-led commissioning since 1994 you do build up a memory from the back catalogue of evidence that is not held elsewhere. The weight of the evidence in this area, in particular, has been open to many different interpretations over the years.

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