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A crossroads for commissioning

Amid all the Sturm und Drang over pensions, it’s hard to believe it’s only 13 weeks since the Health and Social Care Act became law.

Amid all the Sturm und Drang over pensions, it's hard to believe it's only 13 weeks since the Health and Social Care Act became law.

It took 14 months for the act to complete its tortured parliamentary passage, and while putting the reforms on the statute book may have quelled political debate for now, the situation on the NHS front line remains uncertain. As CCGs wrestle with authorisation, and ghost-ship PCTs prepare for their own abolition, GP commissioning finds itself at a crossroads.

The health secretary's preferred path – a charge straight ahead by GPs suddenly willing to put aside their doubts and wholeheartedly embrace his new-look NHS – remains a pipe-dream. For the vast majority, there seems to be a fork in the road.

Will CCGs take practices with them, involve GPs who don't normally get involved and fundamentally rethink the NHS from a frontline clinician's perspective?

Or will they move instead to fill the gap in top-down micromanagement left by PCTs, represent the same old faces who championed practice-based commissioning, and recreate what went before?

The perils of generalising as CCGs develop in a hundred different ways across the country are obvious. But one useful barometer is the extent to which CCGs are taking it upon themselves to performance-manage practices.

Pulse's investigation this week shows there are already ‘inter-practice agreements' in place in more than 40% of CCGs, with almost two-thirds of these referring to some form of performance management. Practices have been told they must submit monthly financial reports, allow detailed scrutiny of their prescribing and referrals and face scorecard rating against a wide range of indicators. If they fail to comply, they face ‘remedial action' or possibly even expulsion.

It is unsurprising commissioning leaders facing unprecedented efficiency targets
are itching to tackle variation in primary care. But the prospect of GPs performance-managing their peers is alarming – and in as much as CCGs are to have any powers over practices, they must police by consent.

Steps must be taken now to redress the balance of power. The GPC has called for CCG leaders to be re-elected ahead of next April – and that must happen. LMCs must be given a formal role. And the NHS Commissioning Board must send a clear message on the limits to CCGs' power. It is all very well for the commissioning tsarDame Barbara Hakin to insist CCGs will not have a performance-management role – but the demand that CCGs‘provide evidence of benchmarking on primary medical care outcome indicators across member practices' rather contradicts that.

And then, of course, there's the wild card. Could anger over pensions – and a reluctance to repeat last week's divisive day of action – lead to a GP commissioning boycott? There is, as we report this week, a growing clamour for one even among some senior figures in the BMA. While it's an idea fraught with problems – how can GPs disengage from
a process they're leading? what equivalent action would non-GPs take? – it would be popular with many.

For all their scepticism, GPs have so far wearily acquiesced to the commissioning revolution. Chances are, they'll continue to do so. But in the current volatile climate, nothing is certain – and GP commissioning could yet head back down the road it came from.

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