The White Paper challenge for GPs: plugging the knowledge and skills gaps

Most GPs will tell you that their primary duty lies with caring for their patients and that the oath to 'do no harm' is their top priority. But how does this core value sit with the new responsibilities set out in the NHS White Paper, which puts consortia of GPs in charge of commissioning a range of health services for their populations?

Will this change to the system diminish the goodwill and trust that many patients put in their GPs? And what is the knowledge and skills gap between what GPs are currently focused on and the new expectations being thrust upon them?

It is clear that the challenge for GP leaders is a large one. One substantial – and fundamental – skill they will need is commissioning care. This requires a set of completely new skills for GPs. As a senior GP confided to one of my colleagues: 'we don't know yet what we don't know'. GPs will need support to assess the needs of their patient populations and to put processes in place to ensure that those needs are met.

GPs will also have to figure out exactly what it means to commission care for whole populations taking health inequalities into account (what does it look like when done well?) and how to work with other colleagues such as existing Directors of Public Health and others to gain this knowledge.

One GP has candidly told me: 'Managing budgets on a large scale is not my thing. It is not what I trained to do'. He went further and said that within his practice 'pressure is being brought to bear on colleagues in the PCT. The last thing we want is to inherit overspending from the PCTs; who is looking at how quickly they (PCTS) can become lean, so that we have a chance of delivering to this agenda?.'

This anxiety underlines the need for another skill GPs will need: building relationships with colleagues from local authorities, acute trusts and other GPs; they will need to learn to negotiate with professionals from the public and private sector and they may need to give up some of the autonomy they have come to enjoy as GPs.

Meanwhile, some GPs are flagging up other skills gaps such as the ability to analyse data about the needs of their patient population to enable quality decision-making about the type of care they should commission.

Others talk about the challenge of 'working across boundaries' (modern parlance for ditching autonomy and embracing colleagues from multi-professional disciplines, including community and social care settings, to deliver health care), building collaborative leadership behaviours, managing and disciplining underperforming colleagues, managing change, etc.

And if these were not enough there is also the challenge of a potential conflict of interest in being both providers and commissioners of health care, and having the ability to differentiate skill sets for each of these two core activities. Such a wide range of responsibilities mean big change.

At The King's Fund, we're doing a lot of thinking – across our leadership development, health care improvement, and policy departments – about how best to help GP leaders, and others in the system, to implement this extensive reform. We are inviting discussion, listening to what you are telling us, and co-designing interventions that we hope will ease the transition.

As part of this, on Tuesday September 7, more than 230 NHS leaders – from GPs to existing PCT leads and other stakeholders – came to the Fund to hear from Parliamentary Under Secretary for State Lord Howe and discuss the challenges of becoming the best at commissioning. We've put highlights of the discussions on GP commissioning on our website. Let us know what you think the main skills gaps are – and how we can best fill them.

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Comments

The white paper has really turned things upside down for general practice. GP views on it are very mixed. There are some GPs who were already engaged with PCTs and commissioning e.g. locality lead GPs who are grasping this and seeing it as a great opportunity to really influence the services that are provided to patients. It is perceived as a transfer of power with the GPs holding the cards rather than the hospital consultants and managers. We will no longer just be asked for an opinion which may or may not influence the final outcome. We will determine what the outcome should be in a way that best serves our patients and will do this by focussing with consultants on clinical outcomes (while keeping it cost effective). There’s also a perception that this is hard ball now. Before we had pbc budgets but there really weren’t consequences for us if we didn’t come in under budget. This meant that although GPs engaged, the other aspects of general practice which directly affected our income took precedence. If there is any link between primary care income and coming in under budget it becomes a more pressing priority for us.

Within my locality, among the GPs who attend the locality meeting (i.e. the more engaged ones) there is still a variety of levels of knowledge on the implications of the paper. In the wider GP community there is still a degree of ignorance and apathy where they fail to realise that unlike pbc this is not something you can just opt out of and leave to someone else – you will still have an obligation to put your own house in order.

As a locality we are trying to work out what is the best consortium structure for us. How do we ensure that the important individuals we need at the PCT don’t up sticks and get other jobs while we try and take time to think about what consortium structure will be most effective?

GPs are really anxious about how they’ll find time to do this. The reality is the bulk of this will fall to the GPs in the middle years of their career i.e. people like me. We tend to be the ones who also lead in the development of the practice and manage the staff. This new role will be a further added pressure on our time. The only solution is to give these GPs protected time. However that means less time on patient contact for those individuals (in our practice I will probably need 1 protected session a week to do this). That patient contact will be picked up by locums and less experienced salaried GPs and therefore does have an impact on individual patient care.

This also creates uncertainty for the career paths of those of us from General Practice in medical leadership roles within the current structure. As Deputy Medical Director I currently have a lead role in writing the quality schedules of our contracts and monitoring performance against that contract as well as increasing involvement at a regional level. I had been fortunate to benefit from the Stretch to the Board Programme in South Central to develop leaders within the NHS. Although the opportunity to have truly GP led commissioning organisations is exciting and I do have the skill set to do it (unlike a number of my colleagues who are going to have a steep learning curve) it’s also really frustrating. I had mapped out a career path for myself involving PCTs and SHAs. This role was quite separate to my GP role allowing me to have a portfolio career. All the familiar structures have gone so I will need to try and establish a role for myself in the new world which continues to stretch me. I’m not sure what the new structure will mean for my continued career development, it all feels very uncertain just now. Consideration needs to be given to how we develop GPs as clinical leaders at all levels of the NHS not just within consortiums.

There seems to be a theme STILL of only using the leaders that have been around for years as the fear of change makes us fall back to what and whom we know. How can those of us who have not permeated the inner sanctums, but who have much to offer, be heard above all the posturing? The GPC see this is not PBC, but do those locally see this? Perhaps not. It takes some doing to look out of the window at the outside world when faced with fear and change as a leader. Agree with Ellie - engagement of the many is the key.

As a Public Health doctor I think there's a lot to be worried about in these proposals. But aside from that, there's a lot of anxiety in the GP world about all the new tasks being foisted upon them without any opt-outs. Many young GPs are very disillusioned anyway, already feeling that they are in an overly-commercial setting with more emphasis on the profit for the practice than concern for the patients they serve. This will only make matters worse. I predict a sudden drop in GP numbers and an exodus to other countries. I think without engagement and support the system could collapse very quickly - I don't think anyone realises how much work and goodwill the "bureaucrats" actually mop up.

Excellent overview, and some very good comments made. Primary care are key to delivery of excellent local services, and clearly need to have really good mechanisms to listen to their communities. I do have concerns, particularly in the gaps that exist between the national specialist commissioning group type activities and local commissioning. This is an area where specialist services sit, and which needs a good knowledge base of what really is a high quality service, and an overview to get really good whole system value and sustainability. Few are passionate about mass spec typing of bacteria, electron microscopy units or neurogastroenterology! The creation of specialist trauma units is another example of centralisation over more locally provided services. It will be intriguing to see how these types of activity will fit into the commissioning structures in future. I am optimistic that this will give patients a greater say but think we have to get better information to inform everyones decision making.

Vijaya,

You have articulated some of the problems with the new proposal really well!

I am concerned that there are so many unknown that I am not confident that the changes will deliver better care for patients, reduce health inequalities or deliver improved clinical outcomes.

I would urge all of us involved in the NHS to do everything we can do get robust and sustainable implementation of the changes. We owe that to our patients.

Kar nice as you are, could you take time to explain your comments in lay person terms?in order for a response from the patient perspective.

GPs will also need to learn how to engage with patients' representatives, if their voice is to be heard and given due weight in the commissioning process.

In the nature of things, some GP's will be very successful in adapting to the new way of working, but others will fail and fail badly. The key will be in the way GP's manage the relationship between their duty to care for patients and the way they "manage" the new management structure be that with or without the necessary skills.
I wish I could believe that the planned changes will be and are for the benefit of all patients, I fear that this is not the case. The underlying reason, in my opinion, is simply to balance the books at all cost and to shift the burden on to that of GP's and others who are ill prepared for what is to happen.

Not every single GP will have to have to the knowledge, skills, attitudes listed above. But I know there are a significant proportion of GPs with the right attributes to move this agenda forward. Support through open leadership programmes, real time leadership development, mentoring and practical workshops will be important. But the key issue for current and future GP leaders is whether they can really commit to what needs to be done in term of balancing clinical and managerial workload. This process cannot be carried out on one day a week or during lunchtimes. It will require clinicians to cut their clinical commitments and to concentrate on this. This is a big ask. To give up what they know and have trained for a job that is going to be difficult and that will most probably not have the same level of job security. So the starting point should be to have developmental conversations with current and future GP leaders to discuss this and the issues in the article above.

A number of the points you raise were echoed by GP's and GP Commissioning groups in a recent East Midlands consultation on the White Paper held with the Under Secretary of State for Health.
Question included who will be the arbiter for GP's when allocating resources on the patch? If Publich Health Consultants sit with County Councils how will their current role of advising commissioners be discharged? A number of health boundaries are coterminus with Acute Sector will this change to Local Authority boundaries?

Alfred.