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

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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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Dr Jackie McGlynn

GP and PCT Deputy Medical Director,
Comment date
23 September 2010
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.

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