What are the main opportunities for GPs and the primary care team in the new policy?
MD: “This is the time for general practice to up its game. Current changes allow GPs and general practices a major role as local leaders in determining the nature and quality of all local services available and improving local health. Potentially, they can move from being peripheral to this process to becoming the driving force within it.
“For the individual GP too, it is a welcome extension in each's role as a local doctor. The ability to change the lot of one's patients outside the consulting room and have a major say over the services available and local health initiatives gives us a once-in-a-lifetime opportunity to really improve the lot of our patients - not only in the surgery, but in their daily working lives.
“It is for these opportunities that NHS Alliance has been pressing for so many years, but too often been thwarted by a rather centralist, over managerialist and secondary care-centric system, which has too often chosen to ignore the views of frontline clinicians and needs of patients.
“If we get it right, we may see a return to the sort of fruitful equal relationships between clinicians and managers at the frontline that were the driving force in the most successful primary care groups and total purchasing projects.”
And where are the main threats?
MD: “The threats from general practice are that insufficient GPs may be up for it or up to it. It will require around 500 inspirational and effective GP leaders to achieve sufficient traction. They will need to be enabled and supported and right at the front line, they will need to be able to enthuse even the most unenthusiastic GP, primary care professional or manager.
“The dangers outside are that things will not be sufficiently changed to allow them to succeed. Already the forces of the status quo are hovering and harping. They say that GPs don't understand issues of governance and accountability, which may be true in some cases. Most will require some support to get these things right.
“Many of those who say that GPs aren't up to it, however, are really just saying – ‘keep off our patch!’ It will not only require the Department of Health, SHAs and PCT managers to loosen, devolve and engage. National guidelines (such as those coming from NICE) may derail the new GP commissioners trying to keep within budget and Payment by Results (the national tariff) in the context of powerful acute foundation trusts may prove another challenge without some alterations.
“The threat from Government is that we may have a prescription that will suit some GPs and localities, but not others. For instance, the model of a hard budget, which might incur individual GPs in personal profit or loss may well appeal to some GPs but may not be right for others.
“This process of GP commissioning needs to be enabled, but organically, in a way that suits local people and clinicians without letting anyone off the hook of being responsible, in some way, for local services and the cost-efficient use of them.”
Have GPs 'won' the battle with NHS managers?
MD: In the context in which the question is asked, yes. If they had, in reality, it would be a pyrrhic victory.
“What they have won is the right and ability to work as equals with managers and redevelop respecting and effective relationships between clinicians and managers. It is not an either-or thing, and in the days ahead of GP commissioning, clinicians will need managers every bit as vice-versa.
“The odd thing about commissioning is that when I talked to audiences in the mid-1990s, they were 90% clinicians. By 2005, they were mainly managers. To be effective, commissioning must be a process fully involving both, and I think this is where Government policy is currently leading.”
What are the key practicalities about a move to hard commissioning budgets, associated with risk and reward?
MD: “There are some key practicalities around how you calculate the budget and what happens if you underspend or overspend.
“There is also the issue of ‘service risk’, which clinicians can to some extent control; and that of ‘insurance risk’, which can be prey to outside forces and freak occurrences. GPs are not actuaries, and unless they want to be, they are dangers in asking all GPs to be.
“Some may be happy with accepting personal risk - allowing for profit as well as loss. Others may be very put off by this - and in order not to deter them from commissioning altogether, we will need other models, which may not affect their personal income. They might, for instance, be paid ‘pro rata’ for commissioning work.
“Some clinicians and patients will think the idea of "profiting" from an underspend could be translated into profiting from under treating patients and keeping resources from them.
“GPs are very happy to be personal advocates for their patients. The idea of balancing the local population with a patient is new to many and though this new role is to some extent consequent upon their daily experience as effective commissioners (referring, prescribing and order diagnostic tests), few see themselves as entrepreneurial businessmen. Entrepreneurs, innovators and local leaders - yes - but not businessmen in the Branson mould!”
How will clinical commissioning - getting GPs into management - work, as the NHS management budget is cut by 1/3 over the next few years?
MD: “Clinical commissioning won’t work unless there is sufficient management resource and unless GPs themselves have sufficient headroom in time to do the job.
“If this part of reform is underfunded, then it will be unable itself to achieve the cost savings and service improvements that I believe it can achieve.
“Part of the solution here is for managers to be in the right jobs. For too long, some of the best and most experienced managers have been doing high strategy, when they are needed to be turning cogs and innovating in frontline organisations. So some of the solution will be a question of managers being in the right jobs and enabling practice managers to step up to the plate.
“We have tried to do commissioning on a shoestring to date, and experiences from the USA and elsewhere suggest it has to be properly resourced. This is one risk that the Government has to take in the aim of creating a more cost efficient health system in the long term.”
GPs' readiness and ability to form clinical commissioning consortia will vary. How can the new system manage this variation?
MD: “By allowing different GPs, practices and consortia to proceed at their own rate and organically. That doesn't mean letting anyone off the hook of being responsible for commissioning in some sense, but it does mean everyone being able to work according to the level that they have reached.
“It is right that we should accept this variation at a time when we are not sure which model will prove to be the most cost-effective. For instance, hard budgets in the USA have not had a very successful history and though I am sure that GP commissioning in some sense will be the right way forward, the jury is out as to whether this is something that requires hard budgets - or simply the right culture and co-operation between clinicians, managers and local people to enable local services and health initiatives to improve and become more cost-effective.
“One of the dangers, for instance, is that people focus too much on hard budgets and commissioning consortia, and insufficiently on what they are actually achieving and what outcomes they are improving.
“So NHS Alliance would argue that variation is inevitable and appropriate and you cannot homogenise the heterogeneous.”
The new system fundamentally accepts that some clinical commissioners will make a healthcare pound go further than others - a 'postcode lottery'. How will primary care take to this?
MD: “We already have a postcode lottery. To some extent, this will be averted by some national imperatives - e.g. drugs that NICE says should be given for various cancers.
“If you localise, then local variation is inevitable. Furthermore, it is also desirable at a time when we are trying to find out what are the things that enable one commissioning consortia to provide better services in health for its local patients than another.
“Once we are able to describe the right formula - hard budgets, strong leadership, good personal relationships between practices and engaged local population... whatever, then we will be able to develop a more standard formula for what works best and roll this out as a means of bringing up those with lesser outcomes to the standards of those with better outcomes.
“Needless to say, some local variation will be appropriate given that local needs and priorities are bound to vary as well.”
How comfortable will the primary care team be with a far more explicit role in rationing care and reconfiguring and closing services?
MD: “It is a role that they are going to need to learn and embrace. I think a primary care team would feel uncomfortable in rationing and reconfiguring if it were seen to profit in the process. Also, if it felt isolated from its local population.
“The trick with GP commissioning will be to build on the individual GP / patient relationships (a million consultations a day), and extend this as an "unholy alliance" between local clinicians and patients. Then collectively, and with good leadership to decide what matters and what doesn't, just like in the recent Chancellor's Budget, that will mean some things being prioritised, some less so and some closing altogether.
“My own frontline experience of rationing is that patients and local people have less trouble with this concept than clinicians! A close relationship with local people and media will be essential in this respect.”
Can politicians accept clinically-led service closures in their constituencies, or will every case be a special case?
MD: “If closure were simply clinically led then I suspect that politicians and clinicians would be on a collision course. The only way to obviate this is for clinicians to be working closely with their local population and for the population to see themselves as commissioners rather than as standard bearers for a given district general hospital, community hospital or particular service. Clinicians will only really listen to clinicians and patients only to other patients.
“In an ideal world, politicians would not then be challenged by patients on closures because the patients and the clinicians would already be behind any recommendation that they had collectively worked up together.
“Yes that is a bit utopian and there will be some clashes, and I look forward to the first case of a politician standing against closure of a local hospital and being outnumbered and heckled by local people and clinicians!”
Is the data and IT infrastructure available to make clinical commissioning work?
MD: “No - not perfectly. However, you can use data as an excuse for not doing the nuts and bolts. Those nuts and bolts are about GPs examining their use of referrals, prescribing and diagnostics. They are about being aware of patient experiences and using feedback from patients to improve services.
“If we try to run the NHS and GP commissioning only from data and account sheets, we will miss the point. The main reason, for instance, that many PBC consortia want hard budgets is simply because they have never been able to construct an adult working relationship with their PCTs. It is quite possible to do this without a budget provided the culture, mutual respect and trust are right.
“Where they are, holding of budgets or the availability of accurate data will not be necessary to achieve desirable outcomes.
Is the management capacity and capability available to make clinical commissioning work?
MD: “It is not perfect yet in terms of capacity or quality. Nevertheless, World Class Commissioning and Practice Based-Commissioning have made a good start in sharpening up managerial skills in commissioning and initiatives such as the NHS Alliance PBC Academy have shown that people can quickly pick up the necessary skills once they are clear about the aims and objectives.
“Commissioning is fundamentally simple. It is about knowing what you have got and what you haven't got, planning change in dialogue with local clinicians and people, making sure that you got what you wanted and keeping in budget by making sure that clinicians and local people are part and parcel of local housekeeping.
“Yes, the processes of contracting and the like get pretty complex but they are only processes and ultimate success won’t depend upon them.
How will the new system cope with the steady 28% of GPs who consistently tell the DH PBC survey they disagree with the policy?
MD: “Every professional body will have its ‘malcontents’. Some of them will continue malcontent or apathetic whatever, while a sizeable majority can be enthused by the right peer leaders and by seeing themselves as having a role in the new way of things.
“The reason why so many GPs are alienated is because they feel that they have been under attack from politicians and senior managers for many years or, those who wanted to do something, felt permanently blocked in being able to make a difference.
“If we can get GP commissioning right then this 28% could be further reduced. Peer pressure will be by far the strongest force in changing that. In some cases, one or two practices may be left out by their peer group simply because they are unwilling to ‘play’.
“Someone will need to performance manage those GPs and practices (possibly the PCT) and those who don't want to ‘join up’ may find that life is harder as a refusnik than it is within the fold of other GPs and practices, who are looking for some sort of participation in their aims.
“There will always be leaders and followers. Some of those followers may simply need to keep an eye on their use of resources and advise, on occasion, in areas in which they have a deep personal interest. That is quite sufficient for the majority of GPs, apart from the needed leadership force of around 500. If we only have a grossly negative rump of GPs and practices - of say 10% - then that will be a fraction of what we have got at present!
What else is needed to make this work?
MD: “We need to allow GPs and practices to develop at their own rate but within the overall aims and ambitions of GP commissioning.
“GPs need headroom and proper management support. They need to feel that they really are masters of the process, rather than pawns in someone else's game and being offered a poison chalice.
“The latter needs to be a first priority of the Coalition Government to be able to persuade GPs that they really are being given a once in a lifetime opportunity, as I believe they are, rather than being cynically cast as the ‘fall guys’ in a system that is set up to fail and could spell the end of the NHS.
“The NHS collectively and hopefully led by GPs, practices and frontline managers need to develop a ‘Dunkirk spirit’ that could demonstrate that the NHS uniquely can solve the health crisis that every developed country finds itself in today.
Does commissioning need regulation? If so, of what kind and by whom?
MD: “Of course there will need to be some regulation and governance, but it should be a light touch and not obstruct progress and innovation.
“Nor should it be imposed from outside by people who may not be sympathetic to GP commissioning or understand how it works. Any system should be developed with consensus by the GP commissioners themselves.
Are GPs sufficiently corporate beasts to drive effective commissioning, out variations in clinical practice and close services or even whole hospitals?
MD: “The most common personality characteristics of the GP is ‘the lone rebel’. We are not traditionally a corporate lot and our patients often value us for being highly individual and their best advocate.
“Clinical practice, however, is becoming more corporate with accepted good practice leading to greater uniformity in clinical decision-making.
“By analogy, I think the time is ripe for a greater deal of corporateness in terms of how we use resources and how local services and health initiatives pan out. It means that we shall lose the prima donnas and mavericks, who have provided much colour to general practice over the years, but we are moving into a new era: one where general practice will have a vastly expanded role and remit, and will need to accept the responsibility and accountability that comes with it - that means corporate accountability and responsibility.
“Yes, I think we can adapt and become corporate where necessary and retain our individuality in our surgeries.”
Is this GP fundholding or locality commissioning?
MD: ”It is the best of both, in the right hands!”