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At the heart of general practice since 1960

GPs who want to commission well need to quit general practice

John Deffenbaugh has a lot of respect for GPs’ business skills, but would think twice before handing over NHS budgets to the profession.

GPs are the last people who should be put in charge of commissioning. GPs are small business entrepreneurs.  They sell a service to the NHS and have a keen eye on the bottom line, the use of their limited time, and the quality of what they offer patients.   This is a micro perspective, dealing with individual patients who come through the surgery door. 

GPs therefore have to be very operationally effective, and because of their targets and payment mechanism, they need to align this patient activity with the income they can earn.  There is a very strong task focus that drives this transaction and the GP mindset.  Not to mention a somewhat individualistic and maverick streak that tends to be a trait of small business people.

Commissioning could not be more different.  Rather than a small micro business focus GPs will have to take a big picture, macro perspective.  Instead of individual patients, GPs as commissioners will be dealing with a complex system.  And rather than tasks, GPs will need to think about the inter-related processes of patient flow and dependency within their local health economy. 

This is oil and vinegar.  Many GPs are therefore absolutely right in their conviction that this is not for them.  Yet they are being shoe-horned into the commissioning role.  What should they do?

Well, some GPs will take to this new challenge like ducks to water.  This was the case at the time of GP fundholding, when some found that they did not really want to be GPs, but were rather good at being fundholders.  The same is true this time around.  So if you think this is for you, then stop being a GP and become a commissioner (who happens to have training as a GP).

Here are three ways in which GPs can make the step change into commissioning.

First, take a strategic perspective.  GPs as commissioners will need to raise their eyes up and look at the whole system they either control or can influence.  This is not just within their NHS budget, but beyond.  Take for example mental health.  The costs the NHS incurs are one thing, but the wider human costs and output losses can be over four times this amount.  Estimates of annual total cost of mental illness range from £70-90b. 

Taking a long term, total cost view will enable GPs to make a step change in service design and delivery that brings a fix to a priority area that has been a Cinderella service for way too long.  After all, GPs see these problems first-hand through the disproportionate number of their patients with mental health issues, so it is only logical to compound this up to a system perspective.                   

Second, GPs as commissioners will need to engage, influence and motivate a wide range of stakeholders.  There are the practices and partners in their own area, with a focus on improving quality, reducing variation, and maximising spend.  Tackling the outliers will be paramount.  Then there is the range of providers they will have to convince to change their ways.  This will not be easy, especially those FTs that think they rule the roost. 

There is also the engagement of patients, communities and the general public.  This is where GPs can really score.  They're the closest to patients, and a realistic explanation about the pros and cons of certain services, be they community hospitals, maternity services or A&E, will go a long way to stripping away the veneer of public ignorance about quality, safety and cost.

The third challenge is to prioritise and achieve service change.  This is the only significant way to deliver the challenging NHS savings targets, but so far it's just been about tinkering at the edges.  The NHS is still an acute-driven illness service, so changing the balance is like turning the proverbial tanker.  However, GP commissioners owe it to future generations to make this work.  The benefits of telemedicine or other technologies are still being ignored.  As trusted professionals, GPs have the opportunity to unhook the public from its obsession with bricks and mortar. 

GPs therefore have it in their grasp to make this shift to commissioning.  What is required is to stop being a GP, but instead to have this knowledge in the background to inform the new role and ways of thinking.  Reliance on commissioning support is not the answer, since that will end up being a substitution for GPs learning about commissioning and making the necessary changes.

So GPs who want to make this change can be the right people to lead commissioning.  Of course they will need support and development to get into the new role, but this is something they can control, as long as they stop doing what they were trained to do.  Stop being a GP.

John Deffenbaugh is a director of Frontline consultancy

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