Since the new year and over the next few months the development of GP-led commissioning is coming to the real crunch point.
While the government rhetoric about the Health Bill has remained one of aiming for the liberation for GP commissioners, the reality of the GP experience has been one of tighter and tighter control.
As the February press release from the commissioning coalition of the National Association of Primary Care and NHS Alliance - both strong supporters of the reforms - puts it: 'There is a risk that the NHS Commissioning Board (NCB) will replicate "more of the same", not least because many of the people involved in all of the "layers" of the NCB, at sector and local office level, will be the same people - risking the same behaviours.
'This then adds to clinical commissioners' concerns and perceptions that they will be suffocated, instead of liberated, which in our view, is fundamental to the success of clinically- led commissioning.'
Pressure on CCGs
The past few months have seen intense pressure on GPs to conform to the NCB's expectations on a number of fronts.
GPs are being told how big their commissioning organisations should be, irrespective of the organic relationships between practices that they have themselves developed.
The move to bigger and bigger confederations of groups of GPs has been forced by a cookie-cutter approach to the right size of organisation rather than a recognition that clinical commissioning groups (CCGs) have to develop the real allegiance of GPs in the day-to-day peer experience of commissioning conversations.
If CCGs fail to deliver the legitimacy that GPs will give to each other in their peer-to-peer conversations, you are left with very little substantive change from PCTs.
The main driver on the size of CCGs has been the fact that the NCB wants CCGs that cover bigger sized populations which will give them fewer CCGs to authorise and performance manage.
There has been a similar experience for GPs looking to employ their future staff in CCGs. While most want to directly employ the staff who will provide them with their commissioning support, the NCB is trying to make them use staff employed by commissioning support organisations.
CCGs are being told that they will be allowed a certain number of staff per head of the population (the going rate is 10 staff per 100,000).
This number has been created to ensure that the CCG will get its remaining commissioning support from the organisations hosted in the NCB.
If you are not allowed to decide for yourself the size of the organisation or the staff you are employing then to what extent are clinicians running these organisations at all?
- Paul Corrigan is a management consultant and former adviser to Tony Blair. More at pauldcorrigan.com