Them and Us
As local authorities and GPs prepare to join forces on commissioning, both are acutely aware they face a bit of a culture clash. So how do they see each other – and what is the way forward? Emma Wilkinson explores
‘This is a marriage of convenience. You have to ask, if these two met each other in a bar, would they actually hit it off?'
Commissioning consultant Gerry McLean might be being slightly flippant, but he raises a good point. Local authorities and GPs have been thrown together and told to play nicely. And yet they're both doing so with huge financial pressures hanging over their heads. So the time has come for a heart-to-heart about how to overcome potential differences and make the relationship work. A useful starting point for some health and wellbeing boards has been to hold forums for GPs and councillors to overcome strongly-formed – but not necessarily accurate – perceptions of each other. So what do GPs think of councillors and vice versa?
‘GPs want an evidence base for everything'
As a rule, GPs are scientifically minded and feel most comfortable when confronted with concrete evidence that something is going to work. Evidence-based medicine will have a strong part to play in CCGs. But an obsession with evidence can be unhelpful. Kingston Council leader Derek Osbourne says lack of evidence can often be an ‘excuse' from GPs not to do something: ‘You have to think about how you would get the evidence in the first place.'
The way forward
Mr McLean says GPs are attached to their usual evidence-based approach because it ‘reduces the risk' of getting it wrong – but for health and wellbeing boards to be ‘truly innovative' they might have to agree to a more flexible approach, even if that means not being as sure of the outcome.
Another useful hint, when appropriate, is to prepare an evidence summary to distribute before a meeting so it can be digested in advance, avoiding board members getting lost in the conversation.
Dr Jonathan Shapiro, a former GP and senior lecturer in health services research at the University of Birmingham, points out: ‘If you always believe the other side has to speak your language rather than learning their language, you'll never get anywhere.'
‘GPs are the inexperienced new kids on the block'
Local authorities are feeling unsure about how to view GPs – these independent contractors who are very inexperienced, says Mr McLean, ‘especially at dealing with population health matters'.
‘CCGs are very, very new,' says Richard Humphries, senior fellow at the King's Fund. ‘And local authorities and GPs have not had a relationship before, so this is a new world.'
The way forward
Being the new kid might not be such a bad thing, says Mr Humphries, as GPs can complement the ‘experience' and ‘stability' of local authorities: ‘GPs can bring fresh commitment and energy to the relationship. It is all about awareness of different skills.'
Management consultant and former special health adviser Professor Paul Corrigan adds that the new approach of CCGs might be just what is needed to shake the system up: ‘GPs do have experience of contracting and they find the nature of the contracts PCTs have with hospitals weird – you don't pay for a service you don't get. So I think it's useful to think the newness of GPs could bring something different to the table.'
‘GPs are impatient risk-takers'
GPs can be seen as ‘maverick', says Dr Michael Dixon, NHS Alliance chair: ‘It comes from being independent contractors.'
Not used to being part of a large organisation, such as a PCT or a hospital trust, GPs are unused to the machinations this brings.
Mr McLean adds: ‘There is a perception that GPs are unconcerned about playing by the rules and make decisions on the spur of the moment.'
The way forward
‘Clinicians like to make decisions and then get on with it,' explains Dr Dixon, adding that this is very different from the local authority world where everything happens by committee and takes longer. ‘But I would like to think that they can meet somewhere in the middle – that the conservative views of the local authority and risk-taking GP perspective is actually a good mix.'
Mr McLean says: ‘We do need to crack these perceptions. We need to get everyone round a table and talk honestly about how they see each other and what their motivations are.'
In addition, says Dr Shapiro, the different perspectives brought by local authorities and GPs could be useful – but only if both realise they need each other and are ‘more open-minded than they are at the moment'.
‘GPs are too focused on disease'
Professor Corrigan says there is an ‘anxiety' that GPs will not have a ‘whole-population view'. And there is a potential clash of priorities, adds Dr Shapiro, with ‘GPs concerned about healthcare and local authorities concerned about health'.
The way forward
‘The jury is still out as to what health and wellbeing boards are going to be doing,' says Dr Shapiro. ‘I have misgivings about local authorities' ability to commission care.'
But he says the key is to focus on the areas that both sides see as important: ‘Elderly care and children in need are the two areas where there is potential to do much better.'
Professor Corrigan agrees: ‘Local authorities know there is a crisis in adult social care and GPs know there is a crisis in bad patient pathways for the frail elderly.'
Ensuring focus, he says, on areas such as this where both have a strong interest will mean both GPs and local authorities ‘come out stronger'.
‘Local authorities are bogged down in bureaucracy'
‘With anything where you get more than a few people around a table, it seems to create a lot of process,' says Dr Paul Charlson, a GP and Conservative Medical Society chair.
‘Delegated authority' is perceived to be a problem, says Dr Shapiro. But he adds that it depends what is meant by ‘bureaucracy'.
‘Their processes are often very slow,' he says. ‘Most GPs will cite examples of children taken into care – everyone covering their own backs and making sure processes are covered very thoroughly.'
The way forward
GPs are used to dealing with PCTs, not exactly renowned for being unbureaucratic.
‘It's about good bureaucracy. These things have to be done – it's about getting it done in an economical way,' says Dr Shapiro.
Dr Dixon says local authority experience with corporate responsibility and due process could be invaluable to GPs: ‘Everyone has to be accountable, but we can hope CCGs may be a bit more fleet of foot than previous organisations because they won't be bound by traditional process.'
Cllr Osbourne says the image of local authorities being overly bureaucratic is an old-fashioned one: ‘I think GPs might find local authorities to be a refreshing change.'
‘Local authorities are addicted to meetings'
Public-sector organisations like local authorities love to have a meeting, says Dr Charlson: ‘I don't want to spend three hours in a meeting because I don't have the time.'
PCTs suffered from exactly the same problem, he adds: ‘They would spend hours focused on dotting each i on sections of minutes instead of getting on with work.'
The way forward
‘We need to have a focus, instead of ethereal committees where we all just chat and think about ideas,' says Dr Charlson.
He gives the example of Archie Norman, who when he took over as the boss of Asda stopped all sit-down meetings, leading to a rise in productivity. Having a focus to meetings will also depend on how motivated the parties involved are.
‘I think people are hungry to do business, but I do think it will take several years for cultures to change,' he adds.
‘Local authorities are too scared of upsetting the electorate'
‘Councillors and MPs are democratically elected,' says Dr Dixon. ‘So they have to be seen to be listening to the electorate.'
In theory, says Dr Shapiro, democracy is great: ‘But it makes it very difficult to make unpopular decisions, and in health there is a difference between want and need.'
The way forward
Health and wellbeing boards might actually be a good mechanism for MPs wanting to avoid the bad news story of the hospital closure landing on their doorstep, says Dr Dixon: ‘If the health and wellbeing board and CCG are connected to the community, these decisions shouldn't be a divisive issue.'
And Mr McLean adds: ‘There is tension in this desire to move everything into primary care – the practicalities of that have to be addressed.'
‘Local authorities are too traditional, they don't want to take risks'
Local authorities have been in place, in more or less their current format, for years and have their own ways of doing things.
‘I feel pessimistic about how much joint working will take place,' says Dr Charlson. ‘Right now, it's a bit like speed dating.'
The way forward
Mr Humphries says one key factor is that both sides are under huge financial pressure, so they will need to find new, more economical ways of doing things: ‘The biggest overriding factor is managing this period of financial constraint. That will either bring people together or force them apart. People may have to learn to disagree.'
But he says the wealth of experience within local authorities should be seen as a good thing: ‘They have a real commitment to a healthy local population.'
Dr Dixon adds that one bonus of health and wellbeing boards is that they are non-statutory: ‘So within this, if you mix the very conservative, risk-averse local authority and the risk-taking GPs, it makes an exciting prospect.' He adds that the traditional versus innovative debate may well be won on the basis of local personalities.
In fact, says Professor Corrigan, it is not about one side being old-fashioned – everyone will have to try new approaches because reproducing what we had before will just lead to failure: ‘We need to ask what are the ingredients within both these organisations that we can use to construct something new that can overcome the issues of the past.'
Local Government Association. New partnerships, new opportunities: a resource to assist setting up and running health and wellbeing boards. tinyurl.com/c4nf27y
National learning network for health and wellbeing boards. knowledgehub.local.gov.uk/home
A Department of Health learning event on health and wellbeing boards is taking place in London on 24 April. To request an invite, email healthandwellbeingboards@ dh.gsi.gov.uk
Common perceptions of GPs by councillors
• Want to see evidence for everything
• Inexperienced commissioners
• Impatient risk-takers
• Think in terms of disease and healthcare, rather than meeting all patients' needs
Common perceptions of councillors by GPs
• Addicted to meetings
• Scared of upsetting the electorate
• Traditional, old-fashioned and slow-moving