Health secretary Andrew Lansley must feel that the whole world is against him. How did we get to this point?
I am not a political person, but I can see that the Health Bill is not without flaws. However, most colleagues who have ever offered me an opinion seem to agree that the general idea of healthcare commissioning being led by clinicians and their patients, and enabled by managers, is a good one.
It is the reason that I became involved in commissioning 18 months ago, having previously been a deputy chairman of the LMC and medical director of a GP provider company. The current political hubris surrounding 'the Bill' is a huge distraction to those of us involved in developing clinical commissioning groups (CCGs).
I'm not saying that the noise is wrong, but it presents a dilemma. Whatever the future of the Bill may be, one knows there is no going back. PCTs as we knew them have largely gone (along with talented managers).
Therefore, we have to move forwards, or risk huge vacuums developing in our health economies, just when we need talented commissioners and managers to step up to the plate.
CCGs are all passing through an authorisation pipeline process, demonstrating to the NHS Commissioning Board (NCB) that they can take on all the statutory duties that will be placed upon them come April 2013.
One of the key requirements will be to demonstrate the engagement of constituent practices in the process. This will mean more than just ticking a box, or signing a mandate. It will mean true engagement. The NCB may well visit practices and ask the John Cleese question: 'What has your CCG ever done for you?'
Furthermore, CCGs will almost certainly have a large responsibility for the quality of primary care provision, creating the possibility of further tension between CCGs and their constituents.
Constituent practices in my CCG are probably like any in the country, healthily sceptical, given all the 'noise' in the system at present regarding the Bill. Pragmatically, if our CCG is to progress, I have to demonstrate to them that we are the only show in town, and that we are working in their (and of course primarily, their patients') best interests.
|KEY TO CCG/LMC RELATIONSHIPS|
This is where the LMCs have a vital role. Contrary to what the Daily Mail might believe, commissioning clinicians are at risk of pursuing commissioning ideals without properly considering the legal and contractual obligations pertaining to general practice.
Any discussions about service redesign must address the issue of GPs as providers, and LMCs are ideally placed to offer this viewpoint. Commissioning GPs would struggle with this due to the conflict of interests. Primary care estate is another area where LMCs can offer CCGs help.
In my CCG, we have done a huge amount of work addressing the demand on secondary care, requiring our GP colleagues to spend considerable time and energy developing new pathways of care.
We ensured LMC involvement at every stage to make sure that what we did was fair, equitable and legal, particularly when changes to QOF duplicated what we had already set up last year. LMCs must be involved in the development of legal agreements between CCGs and their constituents.
My CCG has started to address practice variation. There is a risk that we could very easily slide into the sort of behaviour that we used to see from some PCTs, a culture of target setting, and 'punishment' based on poorly conceived ideas of what brings about 'good' or 'bad' performance.
We involved the LMC from the start and developed a programme that sought to understand variation, without automatically labelling it good or bad.
This has enabled us to develop a supportive approach to tackling variation, through targeted education, and provision of accurate data. Each practice is supported in developing a practice portfolio, in essence a development plan for the practice.
In the new NHS, CCGs' primary duty will be to their populations, while acknowledging the place of general practice. LMCs' primary duty will be to their practices, ensuring that they are treated fairly in a changing world, while understanding that we are all working to improve the health of our populations.
CCGs and LMCs must work in partnership to ensure that however clinical commissioning evolves, it is fair and equitable for practices, providing the best possible care for patients within the resources available.
- Dr Kimber is vice-chairman of Coastal West Sussex clinical commissioning group