Dr Johnny Marshall, chair of the NAPC, explains the juncture GP commissioners now find themselves at, following the changes to the health bill.
The NHS has a long-standing culture of central direction. So when the white paper Equity and Excellence: Liberating the NHS was published a year ago with its permissive nature and promotion of autonomy and local determination, the odds on its survival were probably quite short. The ‘pause' has produced a rewind on this liberation, and a year on from the publication of the white paper, clinical commissioning groups (CCGs) are wondering whether the additional tiers of bureaucracy being added to mitigate risk will be at the expense of opportunity.
The most advanced emerging CCGs already adopt good practice around governance because they are driven by a desire to be highly performing organisations accountable to the public they serve. Indeed, many see the reforms as an opportunity to develop commissioning groups as ‘people's' organisations.
The original promise of a membership-style organisation in which clinical commissioning would better align individual clinical accountability with investment decisions, resulting in better health outcomes for populations, is in danger of being lost. The concept was of an organisation in which practices challenged and supported each other in pursuit of excellence and forged closer working relationships across healthcare, social care and with the public. If this fails to materialise, the whole premise on which the success of clinical commissioning is based will surely perish.
If CCGs are to be successful in meeting the challenges currently facing the NHS, we need to balance the need for statutory accountability and an inclusive commissioning process with the need for significant change in how care is delivered locally around the needs of the population.
At present, there are reports that some PCT clusters and SHAs are determining the viability of emerging CCGs on the basis of untested assumptions – for example, an undisclosed running cost allowance, and the commissioning support that PCT clusters imagine themselves providing.
This loses sight of the central purpose and strength of the reforms in seeking to engage practices fully by placing them at the centre of the clinical commissioning process. To do anything less almost inevitably recreates PCTs and risks immediate failure.
Yet the central tenets of the original proposals remain largely unchanged. The direction of travel is essentially evolutionary, particularly with respect to clinical commissioning. The feature on page 22 shows how some of the health bill initiatives are already taking shape in some NHS organisations.
General practice retains a major role in providing leadership through clinical commissioning. It must require all parties to lay aside professional and organisational self-interest in pursuit of excellence through an emphasis on quality, innovation, prevention and productivity – all directed at supporting people living healthier and happier lives. Emerging CCGs should continue to argue the case for flexibility while being open to genuine challenge about how they configure themselves to be the most successful they can be. The interview with Dame Barbara Hakin (page 18) shows how the authorisation process is being created to take into account individual CCGs' needs and wants.
Uncertain times require outstanding leadership, and GPs around the country have stepped up to this new leadership responsibility. The views of the GP commissioners on page 14 reflect how many GPs are undeterred by the pause and are keen to reclaim lost ground. They are challenging themselves and their behaviours as they seek to make sense of what needs transforming. They are forming new relationships with other professionals, with other care partners and with the public.
After years of missed opportunity, the genie of greater leadership within primary care to the benefit of the wider NHS system is officially out of the bottle. In partnership with the public, GPs can imagine, plan and build a successful future for a modern NHS.
Dr Johnny Marshall is chair of the NAPC and a GP in Wendover, Buckinghamshire
