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GP Sarah Riding is determined to introduce practice-based commissioning to Shropshire ­ but her quest has been lonely, stressful, unsupported and unpaid

I am a GP in mid career with fingers in different pies. I am a partner, an appraiser, a teacher and I have this rather nebulous, self-appointed leadership role, whereby I try to change the NHS to make things work a little better. Am I leadership material? Well how can you tell?

But I was delighted this year to win a leadership fellows award from the Health Foundation ­ an independent charity dedicated to improving health care in the UK ­ for my work in practice-based commissioning. The annual fellows scheme offers coaching to 16 NHS clinicians and managers over two years so we can have a real impact on improving patient care. I currently chair the local practice-based commissioning group I set up 16 months ago and my coaching will help me make this a success.

Small beginnings

The practice-based commissioning arena is isolated, lonely, stressful, unsupported and mostly unpaid. It's personally challenging, endlessly fascinating and very occasionally rewarding. It's a relief to have the support of the Health Foundation but it is the support of local bodies, such as the PCT, even fellow GPs, that I lack and would value the most.

I am passionate about improving the NHS and have taken on various roles to try to influence change. A turning point for me was receiving a desperate plea for GPs to stand for a professional executive committee position in 2003. I had a little space in my life and so I said Yes.

I learned many invaluable lessons ­ such as how to put together a business plan, how to chair a meeting and what a complete shambles NHS management can be. I struggled in the PCT. There was no space for clinical leadership, which remained the prov-ince of the managers. It's not that the managers lacked skill and dedication.

I saw many who were passionate about the NHS and patients. Where they failed was in not recognising the primary purpose of the PCT ­ to engage the clinical workforce in modernisation and change. The managers had a few ideas, but not enough. They asked clinicians for theirs ­ but not often enough.

They asked clinicians to lead the process ....not at all. I found it enormously frustrating to work with managers who don't want to hear what you have to say. As a jobbing GP it is pretty obvious where things are in a mess ­ like waiting a year for an X-ray.

With the emergence of practice-based commissioning I have picked myself up, brushed myself down and embraced this second chance for clinicians to lead the way.

Most GPs have no understanding of the impact they have on spending and therefore feel no responsibility for it. They work in isolated units and think things will chug along as always. It can be difficult to pull all these people together to make shared decisions.

I think we can all agree that the NHS is at a critical point. Clinical leaders, GP leaders, are essential if we are to modernise the way services are delivered. Are you aware that 86 per cent of the money spent in the NHS is under GPs' control? Because of the way we refer, the way we prescribe, or the way we use hospital beds. Unless we can influence these patterns, develop alternatives to our old-fashioned ways and support practitioners in the change, the NHS, I believe, will moulder and collapse under the weight of its obligations.

I mentioned earlier that it is lonely and unsupported being a GP leader in the NHS.

I believe that this must change too. Your clinical leaders only have so much courage and tenacity. Like everybody else they find it uncomfortable to put their heads above the parapet without support, feedback, training and an explicit content to their job.

Support structures

In secondary care a structure of support and a potential pathway for developing leaders exists. Medical and clinical directors have fully understood remunerated roles which are performance managed, recognised, respected and supported.

In primary care this structure is poorly evolved and fails to encompass GPs like myself. If we are looking to practices to show the way, through practice-based commissioning, we need to support and nurture the enthusiasm and bravery of those who are beginning to put their heads above the parapet and address support, training and pay.

So I take this opportunity to call on those of you out there who, as leaders yourselves, have the authority to establish such support networks. You might be in the Department of Health; you might be in the strategic health authorities, the PCTs or the LMCs. You may be a medical director, a PEC chair, an LMC chair, a modernisation lead or a leader in education. Wherever you are, I call on you to address this failing with all speed!

Sarah Riding is a GP principal at Shropshire County PCT

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