Dr Michael Dixon was on the radio again today. It happens so often these days that it’s not usually worthy of comment, but this Radio 4 interview with the NHS Alliance chair raised issues for me that went far beyond the vagaries of ‘any qualified provider’, important though that is, and went into the deeper issue of how human nature responds to external stimuli.
Ever since 1989, GPs have had the carrots of increased prominence and influence in the NHS held in front of them; whether it was the creation of the purchaser/provider split, the introduction of GP fundholding, the appearance of PCGs and PCTs, or the publication of white papers with enticing titles like ‘primary care-led NHS’, the GP community was repeatedly promised that each round of reforms would increase their profile and improve the lot of their patients.
But like the Peanuts character Charlie Brown having the football he longed to kick - and it always being removed by Lucy at the last moment - the promises made to the primary care community have never been properly kept. Unlike Charlie Brown, there is now a real risk that GPs will finally recognise the pattern, and refuse to play.
As has been drummed into us for so many years, GPs are generally independent contractors, and their obligation, and the reason why most of them came into practice, was to deliver personalised care to individual patients, ‘doing what they can, and buying in the rest’. Additional wrinkles such as revalidation and QOF points have been added over the years to strengthen this central plank of their existence, but it would be nigh on impossible to compel them to consider the broader issues of commissioning, with its implication of dealing with populations rather than individuals, as part of their ‘day job’.
The only way of engaging the general GP workforce in this work is by ‘selling it’ rather than ‘telling it’, but when deals are promised and not kept, potential buyers move from disappointment to cynicism and eventually walk away completely.
Fundholding was never allowed to realise its potential; primary care groups lost the centrality of clinicians in the main decision-making processes as soon as they became PCTs; the ‘primary care-led NHS’ was distorted by the behaviour of large acute provider trusts, and the move towards CCGs looked as if it was the last chance to add significant primary care common sense to the commissioning of NHS services.
And now, even that promise is being eroded. The introduction of senior managers into CCGs is not the problem, per se, because CCGs will need very senior managers to turn GPs’ decisions into action; it’s just that the ones being hired are generally bringing with them the culture and bureaucracy of PCTs. They are not the innovators and influencers that are really needed to make change happen. And whilst we do need accountability in the CCGs that will be spending enormous amounts of public money, are the mechanical competency hoops through which aspiring CCG chairs and accountable officers are being required to jump the most appropriate ways of developing that accountability?
Clearly we need to prevent unethical ‘gaming’ in procurement, but are the slow, ponderous processes that favour only the largest and most conservative providers the best way of controlling the potential conflicts of interest?
Finally, despite the obvious need to control spending in the mega-industry of the NHS, is the repatriation of so many of the ‘high end’ commissioning issues into central bodies the best way to engender the localism and ‘buy in’ needed to ensure the success of this round of reforms?
My questions are deliberately framed in a one-sided way, as there are few people who would argue that the mechanisms currently being developed are anything other than reductive sops to the political pressures being exerted. For any chance of success, I would suggest only a few key principles are required, and that the great and the good like, Dr Dixon, should be expounding on these, rather than responding to individual operational ‘symptoms’ being raised in the media on a daily basis. These are:
- The centre should be determining what is required, and letting the CCGs work with their providers to establish how this is going to be done. This works to everyone’s strengths, empowers local professionals, and means that there would be considerably less micromanagement than at present.
- CCGs should be considered as health maintenance organisations responsible for the healthcare of their populations. This makes the allocation of specific roles and funds for provision more like sub-contracting than strategic commissioning. This would simplify the perceived conflicts of interest, and reduce the stranglehold on progress being exerted by the artificial bureaucracies of the current tendering process.
- Finally (and probably the most difficult to enact), professional clinicians (doctors and nurses) need to be treated as professionals, and encouraged to make individual decisions within a corporate framework. In that way, one can overcome the paradox that it is only when professionals feel that their autonomy is being respected that they are prepared to act more corporately.
Dr Jonathan Shapiro is a senior lecturer in health services research at the University of Birmingham
