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At the heart of general practice since 1960

Accountability without power

Bliss was it in that dawn to be alive, but to be a GP was very heaven. Or it felt like it, anyway, when the coalition Government came to power in the summer of 2010.

GPs fell over themselves to praise Andrew Lansley, a health secretary who finally seemed to understand the NHS and value general practice, and who had even been married to a GP. He scrapped GP access targets, lit a bonfire of the quangos, then capped a heady few weeks with a white paper setting out the scope of his NHS reforms.

Of course, many GPs had immediate concerns, over privatisation, over how the doctor-patient relationship might change. But surveys from the time remind us that the majority, surprised and flattered, seemed willing to have a crack at commissioning. We’ve been saying for years we could do better, went the argument - here’s our chance to prove it.

How times change. Party-political wrangling and the unsatisfactory compromises of the ‘listening exercise’ took their toll, but it has been ordinary GPs’ myriad individual experiences of nascent CCGs which have most dampened their early enthusiasm.

Uncontested elections returning the ‘same old faces’, an unhealthy appetite for overzealous performance management, a reluctance to properly engage with member practices: it will be no surprise to anyone who’s been reading Pulse over the past two years that many grassroots GPs feel left out. But the key finding of our survey this month - that a clear majority of GPs feel no more involved with commissioning today than they did under PCTs - is striking nonetheless.

Even the enthusiasts have their doubts. When Pulse interviewed 43 GP CCG chairs, off the record, a third told us they were already disillusioned with their commissioning influence. CCG leaders have seen the power they were supposed to wield eroded from every angle; by a micromanaging NHS Commissioning Board, by local authorities, by the non-GPs who now comprise a majority on many CCG boards. When CCG leaders speak publicly of a ‘command and control dynamic’ and a ‘culture of fear’, it’s clear the revolution is in trouble.

The fact that the handover to CCGs is proceeding as planned - and on schedule - is in itself no mean feat. Sir David Nicholson famously described the NHS reforms as ‘so big they can be seen from space’. But if this restructuring has left a majority of GPs feeling no more involved in commissioning, it begs the question: what was it all for?

If clinical commissioning is to be a success, it cannot be a minority sport. The NHS Commissioning Board must give CCGs the latitude they crave; CCGs must reach beyond their comfort zone and genuinely engage with all their member practices, especially the reluctant ones. At the moment, many practices feel they have been given accountability without much power. If all GPs are to take the flak from patients for the tough decisions ahead, on rationing, restructuring and retrenchment, then all GPs must be given a stake in making them.

For all the justified concerns over so many aspects of his reforms, Mr Lansley was right in one regard: GPs are uniquely placed to influence clinically sound, local, evidence-based changes to the way the NHS is run. It must be his successor’s priority to make sure they are given the opportunity to do so.

Readers' comments (4)

  • There remains an unavoidable contradiction.
    Any caring GP who seriously engages with commissioning must spend so much of his/her time doing committee-related work that he/she is forced to reduce patient contact time, damaging the quality of personal medical service to his patients.
    There is not enough time in an average GP's professional life to be both an excellent commissioner of services and an excellent GP.
    GP's who are incompetent, burnt-out,or seeking to foster commercial relationships are the likely self-selectors for commissioning bodies.
    You can't do both jobs really well, unless you are a (rare) doctor who, like Margaret Thatcher, only needs 3 hours sleep a night, or (more commonly), you are quite prepared to desert your patients when the committee calls.

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  • dont worry paul, the present plan is that registars get exploited through an ever increasing training scheme and end up doing all the work anyway. this frees up time to do all the commissioning. that's what we have noticed anyway

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  • As a secondary care doctor sitting on a CCG I have been both surprised and impressed at the way the 5 GP board members have set about their task. 4 of the 5 continue with most of their former GP sessions, the exception being the chair who admittedly has less time to function as a GP. At all meetings the clinicians present have a considerable say on issues and there is regular monthly dialogue with all GP's who have opportunity to vent their feelings on any issues which are fed back to the CCG. Indeed other GPs do sit on sub groups and provide meaningful input eg on quality issues. To date I have come across no major contentious issues.

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  • Most of us share the misgivings about government policy expressed by Clare Gerada and the BMA, so it would be two faced of us to have anything to do with commissioning - besides which we would be ostracised by the enthusiasts.
    The situation requires political action by the rest of us. The Green Party is the only party opposed to managing the NHS by item of service contracts and short-term contracts, rather than by better monitoring and appraising.

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