I recall back in 2002, a local prominent GP telling me “I’ve worked in NHS for over 25 years and seen 15+ reorganisations and not one of those had any impact on my practice”
Of course they hadn’t – he hadn’t let it. He hadn’t `owned’ nor engaged in the reforms. The advent of practice based commissioning (pbc) with devolved GP budgets promised change and GPs began to get interested, but there was frustration because of the differences between their local concerns and commissioning by a PCT delivering for a wider population.
Advent of CCGs did re-enthuse some local GPs who found themselves as clinical leads, able to directly redesign pathways and negotiate with providers in contracting. It could also be argued that some degree of `tribalism’ emerged. GPs feeling that have been regarded for years by consultants as not quite having their status and here was a chance to demonstrate who really had power in the NHS – especially in face of a 45% reduction in commissioning managers. For others, it was an opportunity to make real change for their communities. Tear down the traditional structures and let a thousand flowers bloom said Mao during the Cultural Revolution (though Conservatives prefer `creative destruction’). Early indications are that GP engagement is having a positive impact in some areas.
However, it has rapidly become clear that the `Maoist’ promise of the reforms is already beginning to take a decidedly centralist/ managerialist turn. The lack of checks and balances on the role of the NHSNCB (National Commissioning Board) and the promise of increased performance management around nationally set criteria and area wide Health and Wellbeing Board targets brings with it the realisation that CCGs won’t have the envisaged freedoms. The `thousand flowers’ must all be the same otherwise there would be a `post code lottery’, something the NCB would not countenance. There are also significant concerns over governance within the commissioning structure and how CCGs can quality assure increasing numbers of providers under AQP with less managerial resources. Privatisation of commissioning support does not increase resource and brings with it other concerns. There is already talk in DH on the `optimum size’ of a CCG (and it’s not too far off the size of the early PCTs) so concerns about loss of `local focus’.
There is also realisation that this may be a `divide and rule’ of doctors to bring in the Governments own `cultural revolution’ around a privatisation agenda. GPs may be being `set up’ to take the blame for this, rationing and other failures in the NHS as it is forced to do more with less resource, and against rising patient expectations – ironically, perhaps, fuelled by the CCGs own community engagement activities. These reforms are happening on `Their Watch’ and GPs are very aware of that.
There is enthusiasm for clinical commissioning – GPs like it and I personally believe it is the way forward – but these are not the right reforms to facilitate it. They have not been fully thought through. In some areas I’m sure CCGs will succeed brilliantly and be able to bring some local flavour despite having to with adhere to National and regional commissioning agendas. In other areas they will fail badly and there is little governance provision for failure other than forced merger with another CCG. The risk is that enough failures would discredit the use of clinicians in commissioning for a decade to come.
Posted by: Ian Shaw