Are we looking at reform through the wrong end of the telescope?

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A GP - active in the world of commissioning - recently surprised me by arguing that the government is looking at reform through the wrong end of the telescope. He claimed the focus should be on the reform of GPs as providers not of GPs as commissioners.

The Health and Social Care Bill, as it stands, is almost silent on GP 'provision' and sets out no vision for the future of GPs as providers. For me, a critical question is whether the Bill will support the adaptation and development of the foundations of good care – the GP practice and supporting community services – in order to ensure the provision of high-quality 21st-century medicine.

There are a number of barriers to this provision. The inadequacy of primary care premises, for example, acts as a major barrier to the development of general practice. I remember Lord Darzi commenting on how extraordinary it was that someone with 15 years' medical training relied on a stethoscope as their prime diagnostic tool and practised in an environment hardly changed since 1948. Many GP practices have far more than a stethoscope at their disposal, but in 2007 almost half of GP practices were either adapted residential buildings or converted shops (Department of Health 2007). Similarly, many GPs are inhibited from taking a greater role in the management of disease by their lack of access to diagnostics. And, as we showed in our recent inquiry into the quality of general practice, the isolation of many in general practice leads to wide and unperceived variation in the quality of care.

Along with the Royal College of General Practitioners, we argue that there would be great benefits to GPs working in a more federated way, enabling the sharing and development of resources such as diagnostics, and providing a stronger governance infrastructure. Will the reformed Bill encourage GPs to federate? While the introduction of clinical commissioning groups will drive more collective working by GPs and greater peer scrutiny, as commissioning organisations these groups will not be able to commission direct from their own practices without time-intensive tendering exercises and the establishment of separately constituted arm's length bodies. The NHS Commissioning Board will commission primary care provision, without local intelligence and insight. It is difficult to see how the recent creative use of 'enhanced service' payments (created by primary care trusts and practice-based commissioning organisations under the General Medical Services contract) will be replicated. The proposed Bill could make reform in primary care more, not less, difficult.

Another critical enabler for GPs to deliver high-quality care is the support they receive from community services. The Transforming Community Services programme has resulted in community services passing to a wide array of different organisations: mental health trusts, acute trusts, social enterprises and community trusts. There is a growing anxiety that, for some, transformation might equal starvation, as community services budgets are raided to prop up their new organisations' financial position, and there is little evidence so far of the promised innovation. Transforming Community Services has failed to deliver more integrated primary and community models, and my concern now is that the proposed divide between commissioning and provision will inhibit GPs from developing the models of care needed in the community to support the core users of NHS care, the elderly and those with long-term conditions.

Having looked through the right end of the telescope – I am not sure I like what I see.


Robert Varnam

Comment date
28 June 2011
Perhaps, rather than concentrating on one end of the telescope or the other, we should look at the whole journey, from the community, through the consulting room and the clinic, back to the community? Great commissioning can achieve a lot, but only when properly joined up with everyday general practice - and vice versa. It's this holistic approach that's been missing thus far. As with music, it's not just a matter of having the right notes, it's how you play them that matters.

Elizabeth Evans

former medical advisor,
Comment date
25 June 2011
How refreshing to read something that highlights the issues that matter.
Look at the question of access to bnp for diagnosing heart failure. In many areas this easy accurate tool has been blocked. Preventing GPs from accessing the tools to diagnose illness early has been the goal of managers and hospital consultants for years. Sadly the BMA has not pushed for this, ever.


Comment date
21 June 2011
I have worked in both primary and secondary care for over 30 years. The largest variation in competence -'from the sublime to the ridiculous' has been the capability of GP's. However they are generalists and as such have finite resources and capacity. The system seems to be based on providing incentives for them to do their day to day job- the rest of us work to penalties!!!

Karen Taylor

Comment date
18 June 2011
Finally, someone shining the spotlight on the part of the patient pathway that needs review and scrutiny the most but which appears to have been largely ignored in the debate. Performance information on GPs is scant (QOF being largely about rewarding prescribed activity not outcomes). Yet GPs ability to diagnose or, as happens in most cases, refer for diagnosis or indeed fail to diagnose early enough, is what drives the NHS engine and

Mark Easton

Comment date
17 June 2011
Of course your GP was right. Which would have the greater benefit: ensuring all GPs produced uniformally excellent, high quality, extended primary care, or training up GPs to be expert commissioners?

A more interesting question is why this hasn't occured to politicians.


Comment date
17 June 2011
Great blog Candace. Another fine example of how the idea of GP commissioning on paper is superb yet with ill thought out implementation seemingly appears less becoming. A year ago many of me and my colleagues were in full support of the notions the White Paper suggested however Lansley has done a fine job in convuluting and damaging expectation, inertia and most of all confidence in the policies.

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