The future of commissioning

An RCGP round table debate considered how commissioning could deliver more co-ordinated, patient-centred care responsive to the needs of local communities. Neil Durham reports.

Professor Mike Pringle: 'The NHS in the past has not been keen on variation. How much leeway are parts of the country going to get in decision-making?'
Professor Mike Pringle: 'The NHS in the past has not been keen on variation. How much leeway are parts of the country going to get in decision-making?'

Given the state of GMS contract negotiations, GPC chairman Dr Laurence Buckman is perhaps not the most obvious enthusiast for commissioning.

But speaking at an RCGP debate on the subject, he says the alliance of GPs, community services and local authorities will benefit patients.

'What was originally seen as a land grab for money, either way, hasn't happened,' says Dr Buckman. 'This will be an interesting set of alliances that will probably benefit healthcare for patients in their communities.'

'Under a dozen' of the 211 CCGs in England have difficulties that will require 'extra help' from the NHS Commissioning Board (NHSCB), he says. He commends the Local Government Association (LGA), which represents councils, for the 'very refreshing...way it sees healthcare going in its communities'.

Oliver Mills, LGA associate director of adult services, sector-led improvement, warns that councils face a 28% budget reduction by 2014/15.

But he adds that closer working across organisations is a 'great opportunity'. 'I think the omens are good. It really is a matter for people locally to shape in a way that works for them. The ability to build relationships and use common language is absolutely essential.'

Opportunity or disaster?

But Dr John Middleton, vice-president of the Faculty of Public Health, is far less enthusiastic. 'As public servants, we try to make the best of a bad job. Health and wellbeing boards are the only common ground of the strategy as an engine room to make this happen. I see a need for more pooling of budgets, not less.'

He urges GPs to scrutinise NHS social care winter funding and reablement spending. He wants greater funding for dealing with alcohol problems.

'GPs and local authorities will need to pool their resources,' he adds. 'I've had a lot of conversations with GPs who want more public health. What does concern me is that screening is a complete mess, immunisation is close behind and emergency planning is a disaster waiting to happen.'

Dr Mike Bewick, left, NHSCB medical director for the north of England, is more positive. 'Despite the political ambiguity and disagreement, quite a lot of your colleagues have just got on and done this and that is to their credit,' he says.

He explains that the NHSCB's focus will be on quality and working to an agreed operating framework, which will mean an end to 'decrees from on high'.

RCGP joint vice-chairman Dr Steve Mowle commends GPs for the 'quite remarkable' work they have done simply to achieve authorisation for their CCGs.

He is concerned about commissioner fatigue, believes grass-roots GP engagement is critical and is already thinking about who will take over from the current crop of leaders.

GP training needs

There is disagreement round the table about training needs for GPs.

Dr Ben Riley, right, RCGP medical director of curriculum and clinical lead for enhanced GP training, says: 'How do we consider what skills we need all GPs to learn, and which may be in training, in order to support and enable commissioning to happen? Then how do we enable some of those GPs to go on and develop the extra skills to get involved in commissioning roles?'

Dr Bewick says: 'If you are a young doctor in your thirties with this in front of you, the danger is that you might think, "This is too formidable and not for me." It's got to be made relevant to them.'

Dr Buckman believes: 'Training surely has to turn every GP into the germ of the commissioner, otherwise it will be a minority sport. The range of skills you want to give people takes generations.'

He worries what will happen if the government changes and enthusiasm for commissioning wanes. 'Assuming that doesn't happen, we have to start nurturing the next generation of GPs now.

'I think most GPs in this generation are uninterested. The next generation need not only to be interested but educated into this. The RCGP is central to that educational process. Politicians have to take a little bit of a longer-term view and not come in and chuck it all away.'

Working together

RCGP chairwoman Professor Clare Gerada says: 'What we need is peloton leadership (a cycling term), where we all work together and the force of the group is combined to lead for the benefit of our patients.'

There is enthusiasm for her suggestion that the NHSCB and Monitor consider funding GP leadership training, as is done in hospitals.

Dr Mowle says some in London are already receiving extra population health training. He sees older GPs wanting to move from clinical to leadership roles later in their careers.

RCGP president Professor Mike Pringle wants to know about the freedom CCGs will have. 'The NHS in the past has not been keen on variation,' he says. 'If parts of the country make a perfectly rational decision from their perspective, how much leeway are they going to get?'

Dr Bewick warns: 'People in CCGs will lose interest if this doesn't have a local feel. There's a mutual interest here.'

Dr Mowle says the key to successful integrated care is to avoid excessive bureaucracy. He fears legal challenges to locally awarded contracts, and backs DH work looking at a 'year of care' tariff for complex patients, which would see local government and secondary care share funding, with incentives for avoiding hospital admission.

It is remarkable that the NHS reform programme, criticised for threatening the future of a collaborative NHS, could yet drive a significant rise in joint working across health and social care. There is a long way to go, but this could prove a key factor in how history judges the changes.

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