Exclusive: RCGP roundtable on the future of commissioning

An RCGP roundtable discussed how commissioning could deliver more co-ordinated patient-centred care responsive to the needs of local communities writes Neil Durham.

RCGP president Professor Mike Pringle: 'How much variation on the ground is going to be encouraged?'

Given the state of GMS contract negotiations, GPC chairman Dr Laurence Buckman is perhaps not the most obvious enthusiast for commissioning but he thinks that the alliance of GPs, community services and local authorities will benefit patients.

He says: ‘We’re probably under a dozen clinical commissioning groups (CCGs) that are going to have difficulty because of the way they have set themselves up or inter-personal problems that are going to render them difficult to operate and I think they’re going to need extra help from the NHS Commissioning Board (NHSCB).’

He commends the Local Government Association (LGA), which represents councils, for its ‘very refreshing view to the way it sees healthcare going in its communities in a way that I think the architects could have hoped in fantasy land but never believed could happen.

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

The LGA’s Oliver Mills, associate director, adult services, sector-led improvement, warns councils face a 28% budget reduction by 2014/15. ‘It’s a great opportunity,’ he adds. ‘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.’

Disaster waiting to happen

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 re-ablement spending. He wants greater funding for tackling 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 close behind and emergency planning is a disaster waiting to happen.’

Elsewhere Dr Mike Bewick, medical director NHS Commissioning Board (NCB) north, 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 explains that the NHSCB’s focus will be quality and working to an agreed operating framework which will mean an end to ‘decrees from on high’.

He mentions NHS failures and warns there is public scepticism about medicine’s ability to protect.

‘I don’t believe that’s true,’ he adds. ‘I don’t believe clinicians go to work not wanting to be compassionate or help people.’

RCGP joint vice chairman Dr Steve Mowle commends GPs for the ‘quite remarkable’ work done simply to be authorised. He is concerned by commissioner fatigue, believes grass-root GP engagement is critical and is already thinking about who will take over from the current crop of leaders.

GP training disagreement

There is disagreement about GP training needs.

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 Ben Riley, the RCGP’s medical director of curriculum and clinical lead, enhanced GP training, says: ‘How do we consider what skills we need all GPs to learn and that may be in training in order to support and enable commissioning to happen. And then how do we enable some of those GPs to go on and develop the extra skills to get involved in commissioning roles?’

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 says: ‘We’re at the beginning of a generation-changing thing looking at public health-led commissioning-based way of delivering healthcare. But we are also providing family medicine to a range of problems more complex and less looked after than secondary care than it used to be.

‘That bit of education and training about commissioning has to be part of what you do as a trainee and possibly as a medical student.’

Dr Buckman worries what will happen if the government changes and the enthusiasm for commissioning wanes. ‘Assuming that doesn’t happen, we have to start nurturing the next generation of GPs now. We should be looking at how grow GPs into this new role.

‘I think most GPs in this generation are disinterested, 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 little bit longer term view and not come in and chuck it all away.’

RCGP chairwoman Dr Clare Gerada is keen on ‘peloton’ leadership, a cycling term to signify a group working together, rather than a single ‘Churchillian’ figurehead intent on single-handed transformation.

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 career.

RCGP president Professor Mike Pringle wants to know about the freedom of experimentation clinical commissioning groups (CCGs) will have. He asks: ‘How much variation on the ground is going to be encouraged? The NHS in the past has not been keen on variation. If parts of the country make a perfectly rational decision from their perspective how much leeway are they going to get?’

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

Bureaucracy light

Dr Arvind Madan, chief executive officer of the London-based Hurley Group which includes Dr Gerada’s practice, urges a bureaucracy-light approach that would unleash the latent talent in primary care.

He explains that he is working on a virtual platform that allows GPs to gain opinion from consultant specialists live, potentially within a consultation. A trust on a block contract is keen but another on Payment By Results is worried about funding flows.

Dr David Bennett, chief executive of competition regulator Monitor, says hospital and ambulance trusts remained concerned about commissioners’ ability to manage patient demand.

Dr Bewick says: ‘If you don’t get providers in a room to sort out what to do if you do underperform or overheat, you’ll never get anywhere.’

Dr Buckman says his practice group abandoned e-health because of the difficulty in getting the consultant at the end of the line at the right time even when the hospital was keen and technology in place.

Dr Mowle says the key for successful integrated care was to avoid over bureaucracy. He fears legal challenges to locally awarded contracts. He backs DH work looking at a ‘year of care’ tariff for complex patients which would see local government and secondary care share funding, with non-hospital admission incentivised. ‘In certain parts of China the doctor gets paid if the patient is fit and healthy. This encourages keeping patients well.’

In England trusts lose funding and gain little if admissions are reduced.

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