As a locum GP and in my experience as the clinical lead for cancer and end-of-life care (EOLC) in Tower Hamlets, east London, I have seen opportunities become available as clinical commissioning groups (CCGs) become more established.
Currently 61% of GPs in Tower Hamlets are sessional GPs. Somewhere between a third and a half of GPs in London are now sessional. Roughly 300 new GPs qualify each year in London but in 2010 only 12 partnerships were advertised in the BMJ.
In February 2011, the new CCG was elected representing all the GP practices previously organised under the old PCT covering a population of more than 250,000. Practices were already organised into eight networks and each network is represented on the CCG. Two of the 10 members on the CCG are sessional GPs.
The criteria for sessional GP election was that they had to be based in a GP practice in one of the networks and had to be doing a minimum of two sessions per week at the time of the election, for example not an average over the past year.
Networks of practices
Networks are made up of four or five practices with a network clinical lead and manager identified. Information is cascaded through networks to all GPs on the Tower Hamlets performers list.
Sessional GPs working outside networks, for example out-of-hours, tend to get information cascaded separately.
Owing to the short-term nature of sessional GP work and small geographical areas within London, many sessional GPs will work across performers list boundaries. Currently one CCG blindspot is a lack of analysis of the workforce, which has resulted in uneven dissemination of information to all GPs.
There has yet to be a programme of systematic communication of CCG activities, leadership development and recognition of and dependence on sessional GPs.
There has been a recent review of previously appointed PCT clinical lead roles because they have been perceived as expensive and possibly not cost effective.
Accountability and funding of these roles has been variable and how these roles articulate with the CCG will need to be standardised. Historically some of the lead posts have been funded through public health (as is my cancer lead role) or third sector organisations, such as Macmillan (which funded all my EOLC activities). New clinical lead posts have been developed to lead on care of the elderly, mental health and EOLC funded via the CCG.
The power may currently lie with principal/partner GPs, however this does not mean that locums cannot exert influence and those interested in becoming more active in commissioning should consider developing the following personal, technical and contextual skills.
First, deal with 'impostor syndrome' - as a trained GP you have a right to be involved in commissioning but this is a political role and is this your strength? Review your personal professional trajectory through mentoring and complete some type of team leadership training, such as Myers Briggs, in order to 'manage your managers'.
Second, become competent in an area of interest. This means knowing the pathway and what factors contribute to disintegration of the pathway. Integration not only covers pathways, but also teams (the optimal integrated commissioning team comprises public health, commissioner and GP) and education programmes, so include primary and acute care/specialists on the same platform.
Be confident in your data analysis and ask the right questions, such as: who says and so what? Maintain regular clinical sessions because patients will remind you to humanise the commissioning pathway. Time management is critical both for you and your CCG because meetings are expensive.
Ethical commissioning
As a GP you are obliged to commission ethically, remember equity. Identify service improvement gaps as was done in Tower Hamlets with the development of the GP quick reference on end-of-life care.
Third, understand the future of your CCG. If sessional GPs in Tower Hamlets are 61% of the workforce, is a reversal to full partnership likely in the future with the direction of current initiatives? Highly unlikely, so find out how elections were done and ensure that you meet the criteria in the event that the same are used again; know the key priorities for your area, for example emergency admission avoidance likely to be common; understand how information is devolved - networks, clinical leads and clinical managers - use these or feed back if information is not reaching all GPs.
Put pressure on CCGs to develop and update comprehensive communication lists and look for opportunities to position yourself, for example set up or run the sessional GP group or become liaison person between CCG sessional GPs.
Last, approaching commissioning can be summed up by the old African proverb that says: 'If you want to go fast, walk alone but if you want to go far, walk together.'
- Dr Risi is a locum GP and cancer lead for Tower Hamlets CCG, east London. LRISI@nhs.net
