A disenchanted and overworked profession has no time for commissioning, says Dr Clarissa Fabre.
Last month a Pulse investigation found that 93% of all elections for GP positions on the boards of the new clinical commissioning groups (CCGs) were uncontested. Am I surprised? Not at all.
Why have GPs as a group not shown any interest? One of the major reasons is excessive workload, with many GPs working 12- or 13-hour days. Life as a GP has become an administrative nightmare.
The NHS reforms and CCGs have their avid enthusiasts. The National Association of Primary Care and the NHS Alliance – both self-appointed pressure groups of GPs – head the list, and they have the ear of the Government. Entrepreneurial GPs are putting themselves forward for board positions.
Some of these people are admirable, but I was astonished to hear that CCG board members will be able to set their own pay and pensions. I am also concerned that GPs involved in private provider companies, although they have to declare an interest, will still be able to be members of CCG boards.
Salaried GPs and locums have been excluded from the process in many areas. Although most LMCs are supportive of sessional involvement, the degree of LMC disengagement from and lack of influence upon the process is a major concern. There should be a process of one GP, one vote for CCG boards.
The Government says that most GPs support the health reforms, as shown by the number of practices who signed up to become part of pathfinder consortia. This is clearly untrue – most practices signed up to consortia because they felt they had to.
GPs becoming disillusioned
In the early days of the white paper, many GPs were enthusiastic about the prospect of commissioning excellent services for their patients in an efficient and cost-effective way. We now hear that CCGs will have to merge so that they are large enough to bear the financial risk.
The whole structure has become more complex with clinical senates, health and wellbeing boards, and very strong central control by the NHS Commissioning Board. The initial, attractive concept of GPs in charge is evaporating with every passing moment.
We then hear the former primary care tsar Professor David Colin-Thome pronouncing that GPs will be ranked on referral rates and prescribing behaviour. Why did we all go into medicine? I want to prescribe the best treatment (and I will do my best to give the least expensive alternative, if it is just as good) and I want to refer my patient to the best clinician in the field. I do not want to be forced to refer to a GP with a special interest if that is not as good.
I am perfectly happy to give my patient exercises for his painful shoulder or knee rather than referring him directly to an orthopaedic surgeon. But I do not want to destabilise secondary care, which is another danger on the horizon.
Another unattractive aspect that is emerging with time is the way some of the GP leaders on CCGs are treating their colleagues in primary care. There are threats of exclusion from CCGs if GP practices are outliers in prescribing or referrals, or if they generally do not toe the line. If we thought PCTs were bad, we have not seen anything yet.
We would have been better off with PCTs at the size they eventually became, led by clinicians and stripped of all the excess management. I wish that general practice was a united workforce, with part-time and full-time partners, and locums, rather than the hierarchy we now have with partners and salaried doctors. We are ripe for takeover by private companies – and our patients will suffer.
Dr Clarissa Fabre is a GPC member, president of the Medical Women's Federation and a GP in Buxted, East Sussex
