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.