Viewpoint - Health Select Committee is neither friend nor foe

It means well, but doesn't understand all the issues that have bewitched commissioning, says Dr Michael Dixon.

Dr Dixon: the report seems to a have more than a whiff of 'old think'
Dr Dixon: the report seems to a have more than a whiff of 'old think'

Following its first report on commissioning in January, the Health Select Committee (HSC) of MPs last month produced a second paper after taking evidence from a wide range of bodies.

Its Commissioning: further issues has some gems, but contains old-fashioned undertones, challenging the whole basis of GPs leading commissioning. Its message that commissioning has been too GP-centric is embodied in the recommendation that the new commissioning bodies should be called 'NHS Commissioning Authorities'.

If you think that sounds like replacing PCTs with something like PCTs, you may be right.

Although the report is right in emphasising that GP consortia need to involve other primary care professionals and consultants, it is wrong to be over-prescriptive about this.

Consortia membership
The HSC suggests that consortia board membership should include nurses' and hospital doctors' representatives, directors of public health or a public health professional, a social care professional and a local authority representative.

This is wrong for two reasons. First, tokenistic representation does not guarantee these various voices are properly heard. Second, turning the board into an enlarged primary care group (PCGs preceded PCTs) committee does not help it to become fast moving and innovative.

For instance, while consultants are important in helping to design services, will having them on the board be appropriate when deciding how to prioritise services or decommission various hospital services?

Inherent contradictions
The report contains inherent contradictions. For example, it rightly says 'there should be devolution of authority from the national commissioning board to the commissioning consortia to avoid the danger of an over-centralised service'.

But then it later suggests the NHS Commissioning Board (NHSCB) should appoint each consortium's chair.

There seems more than a whiff of 'old think', particularly when the HSC proposes the NHSCB should commission primary care - thus re-creating that division between practices and local NHS mamagers which made PCTs 'the enemy' to most GPs.

The report encourages co-terminosity between commissioning groups and social care authorities. This makes clear that the HSC really does not 'get' the whole concept of GP practices working together - and the importance of strong bonds between them, their patient populations and their consortium.

So is Commissioning: further issues a reactionary response to the perceived threats of reform? Not entirely. It is right, for example, to suggest GP consortia board meetings should be public. But it should have specified that the NHSCB - which will have the right to dissolve GP consortia it perceives as underperforming - must also justify its actions in public.

The report's finest moment, however, is about choice and competition. 'NHS commissioners should be able to choose the pattern of service delivery, which reflects the clinical and financial priorities,' the HSC insists.

If commissioners think that more choice or competition is required, it should be their decision alone. NHS Alliance chief executive Mike Sobanja, when giving evidence to the HSC said: 'Monitor (the regulator) ought to be a servant of good commissioning not the determinant of good commissioning.'

The HSC goes further by recognising the need for integration can sometimes trump competition. It decrees that 'commissioners will have the power necessary to design, commission and monitor integrated pathways of care'. NHS Alliance principles support this to the hilt.

No doubt the HSC means well. It wants to stop the top-heavy influence of the NHSCB and Monitor which could shackle consortia.

But in the interests of good and robust governance, it threatens to recreate complex, bureaucratic and over-inclusive local boards.

This is miles away from the fast moving GP-led consortia envisaged by the government and the radical model of clinically-led commissioning championed by the NHS Alliance.

The report is clearly written by people without frontline experience of the issues and obstacles that have bewitched commissioning to date.

GPs must lead the commissioning process and practices must identify with it. Otherwise, nothing will change.

  • Dr Dixon is a GP in Devon and chairman of the NHS Alliance.

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