The NHS reforms have thrown up many challenges for GPs, not least being the whole issue of GP commissioning which is now known as clinical commissioning.
This change represents more than nomenclature, it is a representation that as GPs we cannot deliver the changes required to make the NHS fit for purpose without engagement of colleagues both medical and nursing from across primary and secondary care.
The revised reforms make much of partnership and integration of care services, not just with social care but with specialist services.
What does this mean for clinical commissioning groups (CCGs) now?
The challenge is that in the past 10 years we have seen systematic dismantling of our relationships between colleagues in primary and secondary care. Changes such as Choose and Book introduced other players between the GP and the consultant. Educational systems have changed dramatically, taking GPs and consultants down significantly different paths, with the result that in many areas, GPs and consultants no longer have a first-name relationship.
Some would argue that changes such as increased competition and commissioning have produced benefits, destroying the 'cosy' relationships with local consultants. Others would claim that the breakdown of the relationship has unforeseen and unintended consequences of making it harder to get a consultant 'opinion' without generating patient 'activity'.
Certainly the tariff system that was intended to be Payment by Results has become little more than payment by activity.
Although the system works in its current form, the changes in pathways, commissioning and delivery that are required to reach the 'Nicholson challenge' (to save £20 billion over four years) will not be delivered with poor engagement of secondary care colleagues.
The first focus area is communication. As ever this needs to be a two-way process:
- Do you understand the mood in your local hospital?
- Does it understand the current ways of working?
The communication agenda needs a multi-level solution - developing personal relationships, clear communication channels and a shared understanding of the key strategic elements in the CCG plan will be essential.
For many hospital-based colleagues, practice-based commissioning has been a non-event. Hospital activity has steadily risen in most areas, specialist prescribing has been leading the introduction of new drugs and the outcome in some areas has been serious overspends in primary care budgets.
Developing CCGs which act like mini PCTs is not going to work; it did not work with PCTs, why should it work with CCGs? Commissioners need to establish a shared clinical agenda.
On Merseyside the quality, innovation, productivity and prevention (QIPP) work streams have a wide range of clinicians from medical and nursing backgrounds, from primary and secondary care.
These work streams are agreeing pathways for all CCGs and hospitals in the area and QIPP is a primary care-led initiative, with Liverpool PCT's professional executive committee chair in the driving seat.
Agreeing contracts is a potential area of diversion for CCGs. As clinicians, taking time to discuss matters that others can undertake is wasteful. Although oversight is essential, much of the detail of contracts, arguments over specific coding issues and routine performance against contract, can and should be left to the experts in the field, who will then set out to implement the best arrangements for performance monitoring.
Intent and outcome
Having separated out the three streams of communication, commissioning and contracting, it will be necessary to give careful consideration to the perceived intent of any commissioning development plans or strategic shifts in services.
Many hospital physicians will see shifts in services from secondary to primary care as purely money saving and in some ways designed to shrink the hospital or potentially destabilise services.
Taking the effort to be clear that the intention of such shifts is to produce better outcomes and more efficient use of NHS resources will mean that clinicians are less likely to attribute shifts as asset stripping.
In turn that should mean that specialists will be less likely to raise concerns about destabilisation. Ensuring wide engagement and ownership of the agenda will pay dividends because patients will receive messages about CCG plans through many channels, not least their specialists.
Engage and innovate
The proposal to place a specialist clinician on the board of each CCG is, in principle, a sensible idea. However, the requirement that the clinician be above contestability and not from a local functioning acute trust limits their usefulness in terms of innovation and knowledge of current services.
Such clinicians are likely to be retired specialists or specialists from out of the area. As such, they are unlikely to provide any useful, constructive support in terms of pathway development, lacking both the local knowledge and, if retired, the up-to-date clinical knowledge.
Clear engagement with specialists early in the commissioning cycle will provide solutions that have wide engagement and ownership, and a greater chance of success.
Many CCGs are internally focused, struggling with establishment, authorisation and financial handover. Clinician engagement risks being forgotten in the melee and right now is a good time to take steps to engage with secondary care and specialist colleagues. Trusts will, right now, also be seeking to form relationships that will further understanding and collaboration.
- Dr Mimnagh is a GP in Knowsley and director of strategy and innovation at Aintree Hospital Trust, Merseyside