The White Paper: will peer review improve performance for GP consortia?

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The government's plans for NHS reform – set out in the health White Paper, Equity and Excellence: liberating the NHS – place a great deal of power in the hands of the proposed NHS Commissioning Board, which will take on responsibility for commissioning primary medical care services as and when primary care trusts (PCTs) are abolished.

The recent consultation paper on commissioning indicates that the NHS Commissioning Board will be able to delegate this responsibility to GP-commissioning consortia. The paper further suggests that consortia will have a role in 'promoting quality improvement, reviewing and benchmarking practice performance and ensuring clinical governance requirements are met'. In effect, this means that consortia will have a dual responsibility of commissioning services on behalf of practices, and supporting them to improve their performance as providers.

At one level, this proposal recognises the impossibility of commissioning primary medical care services through the NHS Commissioning Board. Improving the performance of GPs as providers requires knowledge that can be derived only from detailed understanding of the work of practices and the populations they serve. Neither the Commissioning Board operating at a national level, nor regional offices acting on its behalf, could hope to acquire this understanding.

At another level, the proposal puts GPs leading the work of commissioning consortia in the position of challenging practices to raise their standards in a way that the best PCTs and practice-based commissioners have started to do. In the words of the consultation paper, this will entail 'peer review and challenge in the first instance to areas where there appear to be unwarranted variations in practice or outcomes, for instance in relation to prescribing or the systems in place to support management of long-term conditions'. The hope is that pressure from respected and credible peers will be a more effective means of performance improvement than previous approaches.

But will it? It is often argued that doctors who choose a career in general practice frequently do so because of the autonomy of family doctors and their relative freedom from oversight and scrutiny. Much hinges on the willingness of GP leaders to take on the commissioning of primary medical care and their skills in engaging in difficult conversations with their peers.

This blog was also published on the Health Service Journal website.


V Richards

Comment date
21 January 2011
I cannot see that much scope for reduced costs with this model, patient choice as I understand it stands little chance of surviving. The main aim seems to be to provide an opening for further private sector take-over of health services, rather than ensuring equal access to good health care for all the UK.

Nigel Starey

Medical diector & GP,
leicester city PCT
Comment date
11 August 2010
Peer review is a powerful tool in safe hands. Locally challenging GP and practice performance has been central to improving commissioner performance and we have already been encouraging the further development of peer review through PBC as much remains to be done.
Unfortunately, the disonance between the white paper and the responsible officer regulations leaves the future clinical governance arrangements uncertain.
Revalidation should be an important lever for assuring quality - but I am concerned that patient safety and service quality are not adequately assured in the arrangements.

Mary E Hoult

community volunteer,
Comment date
06 August 2010
Glad to see others joining the debate.The consortium for my area was established in Jan 2007 some three years ago, the executive board consisted of 7 elected Gps including a GP chair 2 elected Practice Managers and a nurse,how have they faired during the last 3 years?analysis of shareholders/accounts services and manpower needs to be published now before large sums of money is transferred.Who can make this information available?what is the cash situation?has this Consorium been viable during the last 3 years and what benefits to patients have occured?all food for thought before the local PCT is disbanded.Which organisation is responsible for providing stakeholders with this information for them to make an informed choice.

Donal Hynes

Comment date
05 August 2010
The thinking might be a lot more sophisticated than it could appear.
If my practice joins a consortium I will need to behave as a responsible member of that group of practices. If I refuse to act responsibly by, for example, persisting in prescribing in a non-cost effective manner then my partner practices in the consortium will certainly challenge me. If I still refuse to do so, then the consortium will gently mention that I have to leave the consortium as I am pulling the other practices down.
Then I will get a phone call from the Commissioning Board to point out that holding a Registered List of patients requires me to be part of a consortium – otherwise I might lose that that right.
Then I telephone the consortium and ask what to remind me was it was they wanted me to do?
So it might not be just peer pressure but retaining the privilege of holding a registered list of patients that drives the reform.

richard de souza

Comment date
05 August 2010
how eloquent is the lack of response from gp;s to professor Ham's rhetorical questions?
i doubt we have the skills to enact this , and i most doubt those who have least doubt about their skills!

Mary E Hoult

Comment date
28 July 2010
The power will stay where it has always been with the DOH
It is interesting that the person who it is said will lead this
commissioning board is due to leave in September 2011.Who then will take up the reigns?A Patient perhaps?

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