Exclusive interview: NHS England commissioning lead Dr David Geddes

NHS England primary care commissioning lead Dr David Geddes faces a battle to untangle policies left behind by PCTs. Neil Roberts reports.

Dr David Geddes' CV reads like a record of the evolution of primary care commissioning over the past decade and a half.

Beginning his management career as chairman of a fifth-wave GP fundholding consortium in 1997, the Yorkshire GP moved into primary care groups, PCTs and onto the transition team at what was then the NHS Commissioning Board.

His current role as NHS England's head of primary care commissioning, he says, 'evolved' from work on the transition to new NHS structures that took effect this year.

Sat in the somewhat dull, functional and deserted London offices of NHS England at 7.50am, Dr Geddes admits there is a 'hell of a lot to do'.

Joining the organisation from North Yorkshire and York PCT in November 2012 was an opportunity to help shape a new, national primary care framework, he enthuses.

Profile David Geddes
  • Joined NHS England in 2012 to work on NHS reform transition. Now its primary care commisioning lead.
  • Former professional executive committee member and medical director at Yorkshire PCTs.
  • Special interest in community psychiatry.
  • Qualified as a doctor in 1997.

Following the major focus on CCG development in the run-up to April, the key work now is all about how to 'safely transfer all of the 151 different ways of doing things under PCTs into one way of doing things; and get the right balance between national consistency and local variation and flexibility'.

As a GP in North Yorkshire, Dr Geddes says he recognises the importance of variations between, for example, rural and urban practices, and for flexibility determined by local need.

Crucial delivery

But he admits that many of the 'single operating procedures' that will ultimately provide a more coherent national approach are yet to be developed and published.

Work is ongoing, for example, to develop a single policy for discretionary payments formerly made by PCTs for maternity and sickness cover.

Dr Geddes describes how NHS England, through its 27 area teams (ATs), is mapping how these payments are being made across the country currently. In the meantime ATs are having to operate up to four different systems inherited from predecessor PCTs.

'They are needing to live with that inconsistency at the moment,' he says, 'recognising we need to align that. And so we need to be able to describe a consistent approach.'

'It is about understanding the principles and values of what we stand for as an organisation. And then making sure the ATs have not got their hands tied.'

But, he warns, 2013/14 is still a 'transitional year', and there remains 'much more work to be done to deliver a clearly articulated narrative about where our policies take us'.

Since 'the changes', as Dr Geddes refers to the implementation of the Health and Social Care Act on 1 April, there have been floods of reports from LMCs of practice payment problems causing cash flow issues, and even threatening staff cuts (GP, 5 August).

These problems, admits Dr Geddes, resulted from the fragmentation of the practice payment system, with practices now reliant on CCGs, ATs, and local authorities.

'Payments to GPs have become much more complicated. Beforehand you had one paymaster, the PCT, and everything was consolidated,' he says. Following the changes, it will 'inevitably' take time 'for that to get sorted'.

However, there is a need to 'consolidate' how payments are delivered, he adds, hinting at more changes to come. 'It is a challenge, and it certainly is something we are onto.'

Dr Geddes flatly rejects criticism that ATs lack capacity and lost too many staff in the transition from PCTs, and insists problems with communication will be resolved as they begin to develop better relationships with practices.

Need for change

Despite his obvious enthusiasm for some of 'the changes' to the NHS, Dr Geddes admits there are challenges. It's a word he uses frequently. One challenge for the new regime, he says, is that GP commissioners are being taken away from dealing with patients.

'A lot of people who are experienced clinicians are spending a lot of time commissioning. Now, that's a shift away from individual care, much more towards a holistic, community focus, which is great.

'But it means in terms of capacity for patients to see their doctors, when they are now spending time in a commissioning role, it's an issue.'

A theme Dr Geddes returns to throughout the interview is collaboration between various parts of the newly fragmented system, particularly ATs and CCGs, and the negotiation over roles and responsibilities.

On the problem of unfunded work landing in GPs' consulting rooms, he says it is not as simple as making money follow workload.

There is work to be done, he says, on how ATs and CCGs collaborate and co-commission, because funding will in future follow care pathways developed as primary care 'wraparound' services. That will also mean using those funds to commission alternative providers, such as pharmacists, to pick up some of that workload.

Issue of capacity

'Even with the funding, you've still got a capacity issue. So we need to make sure some of the work currently being delivered in primary care can be distributed, if needs be through other contractors.'

'We need to commission our side of the services alongside what CCGs have to commission. I think the real important bit is to commission pathways of care which are focused on making sure patients do get the right kind of care in the right kind of place ... both through statutory and voluntary organisations.

'We need to work more smartly with voluntary services if we are going to achieve that.'

So there will be a 'shift in finance', he says, but the 'critical part' will be 'getting that through CCGs' to allow them to build up the 'community infrastructure' needed.

Funding taken out of PMS contracts under the ongoing national review to ensure equity with GMS could help CCGs fund new services tailored to local needs.

'We mustn't forget that PMS practices were developed in response to the need to be creative in how services were delivered,' he says. 'We don't want to lose that.'

That 'creativity', says Dr Geddes, should now be determined by CCGs, freed from restrictions created by differences in GP contracts.

'We have to let CCGs have that opportunity to have some funding to play with.'

Dr Geddes acknowledges there is 'a lot of anxiety' around the profession at the moment, although he rejects talk of a crisis.

He points to changing demographics and patient demands, financial restrictions and workforce issues. The key for general practice, he says, is to look at 'how we are going to transform' to meet those challenges.

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