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Editor’s blog Sunday 11 July 2010: What happens next, Part Two - making commissioning work: the four kinds of GP

I wrote something about the new system a few weeks back, on the subject of power in the NHS. Part Two has been delayed for fairly obvious reasons, but is now with you.

The new system is coming, whether we like it or not, with tomorrow afternoon's publication of the NHS White Paper. Tomorrow morning I will post a series of questions, which we must hope it will answer.

One of the questions now, therefore, is how the new system can be made to work. And maybe the White Paper will be so brilliant that everything will just fall into place.

Remember "We will stop the top-down reorganisations of the NHS that have got in the way of patient care"?
However, as James Gubb of Civitas pointed out in his guest editorial yesterday,  evidence shows and experience confirms that redisorganising the NHS has real and significant opportunity costs in performance.

And a top-down redisorganisation is undeniably what has been extensively leaked. The leaks have also given us the abolition of PCTs, which slings the Coalition Agreement into the dustbin of history with gay abandon.

How many functions can abolished organisations fulfil?
Let me refresh your memory of the Coalition Agreement, published on May 20:

• "We will ensure that there is a stronger voice for patients locally through directly elected individuals on the boards of their local primary care trust (PCT). The remainder of the PCT’s board will be appointed by the relevant local authority or authorities, and the Chief Executive and principal officers will be appointed by the Secretary of State on the advice of the new independent NHS board. This will ensure the right balance between locally accountable individuals and technical expertise.
• "The local PCT will act as a champion for patients and commission those residual services that are best undertaken at a wider level, rather than directly by GPs. It will also take responsibility for improving public health for people in their area, working closely with the local authority and other local organisations."

Call me old-fashioned, but I would say abolished organisations are going to have a jolly hard time being strong voices and champions for patients locally, not to mention doing non-GP-appropriate commissioning.

But perhaps this is "the new politics".

Back to GPs. It was interesting to see the spin in the Telegraph leak being put on the compulsoryl nature of commissioning for GPs.

This was more than slightly pointless, since  BMA Chair Dr Hamish Meldrum (unwisely giving away his 'entryist' strategy) told the BMA conference last month that all GPs should get involved in commissioning.

Thus making this a slightly silly macho show of political strength.

As has been repeatedly pointed out on this site, there is going to be a significant problem with the 28% of GPs who, according to the DH's own survey, disagree with the policy of commissioning in its practice-based iteration and are not engaged in it.

This led me to think about how you would go about engaging the different types of GPs: different in their attitudes towards and competence at commissioning.

The four  types of commissioning GPs: fellow travellers
The metaphor that makes most sense is based on driving. All very enrironmentally unfriendly, no doubt.

To begin with the obvious: GPs have, in the main, not been actually doing much commissioning. There are your pioneers - Nene Commissining, Tim Richardson, Shane Gordon - but not much and not everywhere.

The commissioning driving test
Which means that unless you are intending to see a significant amount of taxpayers' hard-earned cash being put at significant hazard, you need a commissioning driving test - the best GPs are competitive, and will want the badge.

That also means you want a Monitor for commissioning. DH should not do it - wrong look for 'shrink-the-centre' Lansleyism, and poor engagement was one of the problems with WCC and particularly PBC.

Once you pass the test, you are Category 1 and can drive on your own (with re-examination a possibility, but ideally done via data analysis and 360 degree feedback, rather than through a bureaucracy. Look at how cleverly GPs have scuppered revalidation, and self-assessment of commissioning will not work).

While you're learning, you drive with L-plates and a qualified driver alongside you: this is Category 2.

Category 3 is going to need a smart name, as it is basically back-seat drivers and passengers. These people are happy to cede the active commissioning function, accept commissioning but don't want to do it: they are part of the team, and probably should be - or certainly feel they have been - consulted about which route to take (motorway or scenic route) and where to stop for lunch. They should not, however, be given a say about  the destination: that must remain for the independent commissioning board. You never know, they might even base it in a bit of Cochrane-and-NICE evidence.

Category 4 are your nightmares: opponents of commissioning. As already mentioned, the DH PBC surveys consistently find about 27% of GPs oppose the policy. These are the people in those rear-facing seats in the boot of people carriers, watching the road unfold behind them. To make GP-led commissioning work, you have to split them into Category 4A and Category 4B. The former, you need to win over fast: they may end up being very effective commissioners or supporters of commissioning if this is done right. The latter, you need to marginalise fast - in a caring way, of course.

You also need driving instructors. And it's not wise to automatically assume FESC  & Co (UnitedHealth, KPMG, Aetna et al) can do this.

If they could, we would have heard an endless parade of success stories, and of course have seen published evidence in peer-reviewed journals.

Oh, you're still waiting too?