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What does the future hold for you?

Alisdair Stirling asked two commissioning experts to predict what the NHS reforms will mean for two stereotypical GPs

The Government’s plans to place GP commissioning at the centre of its NHS reforms will affect every GP. But some will be more prepared than others for the changes ahead. How will more retiring, clinically-focused GPs fare in the years to come? And what will become of the so-called alpha GPs, the pro-active entrepreneurial types who have emerged in recent years?

We asked two GP commissioning experts – Dr David Jenner, co-clinical lead for the NHS Alliance’s clinical commissioning federation, and Dr Johnny Marshall, chair of the National Association of Primary Care – to consider what the future holds for two stereotypical GPs.

The profession of general practice has always allowed entrepreneurial GPs scope to display their business acumen. Practices were small businesses even before the NHS was formed and successive waves of changes since then – starting with GP fundholding in the early 1990s – have provided the springboard for generations of energetic GPs to play a wider role in local healthcare provision and to build their practices up into sizeable businesses at the same time.

But although innovations such as fundholding and PMS have been effectively voluntary in that they have allowed practices to opt in, the new reforms set out in the Government’s recent white paper on the NHS are compulsory. GPs must sign up to a commissioning consortium by autumn 2012.

Less business-minded GPs (see doctor A, box below) have traditionally been able to take a back seat, or simply opt out of change and concentrate on caring for patients, but will these GPs now have to brush up their accounting skills and start getting involved in the world of contracts and budgets that commissioning GPs have been immersed in for years?

And what now for proactive entrepreneurial GPs (doctor B, box right)? Do the new reforms give them carte blanche to build glittering new empires? Or will they have to move at the pace of the slowest, dragging their practice partners and reluctant consortium members behind them as they strive for progress?

Doctor A

The white paper makes it clear that joining a commissioning consortium will be a legal requirement for holding a patient list. That means all GPs will have to involve themselves to a greater or lesser extent in commissioning. As if anticipating that a die-hard core of anti-commissioning GPs may prove obstructive, it adds that practices that do not voluntarily join a consortium will be forcibly assigned to one.

Member practices will be held to account for their delivery against commissioning targets, so will doctor A still be able to leave the number-crunching to the commissioning lead in the practice come 2014, when the reforms have bedded down?

Dr David Jenner stresses it was difficult to predict how the reforms would affect individual GPs because the white paper was still out for consultation and its details may yet change. However, he feels little will have changed for doctor A by 2014: ‘GPs will still be able to get on with their clinical work without feeling they have to change their behaviour too much.’

He adds: ‘For the vast majority of GPs, 99% of the time it will feel exactly the same. GPs will have more feedback on their referral and prescribing rates and will have more referral pathways to follow and there may be clauses in their contracts meaning they have to stick to local formularies, but for most that means little change.

‘A minority will face tighter scrutiny of their referral and prescribing behaviours but only if those are outside the norms.’

Dr Johnny Marshall stresses that there will still be a major role for more clinically-focused GPs such as doctor A but suggests such GPs will need to change their behaviour.

‘We still need top-class GPs who are doing a great job as a clinical GP, but they’ll need to engage with the quality agenda and, more importantly, they will need to be vocal.

‘The whole system depends on every GP having a voice on behalf of his or her patients as to how the service is provided. The whole thing could fall down unless GPs keep being their patients’ advocates as regards service provision. And that means actively contributing to the decisions.’

‘They will also need to be more proactive and less reactive and illness-based in their outlook,’ he adds.

However, he says that the skills GPs need to do this and play a part in the new process of commissioning care are the same ones GPs use daily in consulting rooms across the country, rather than business skills: ‘Building relationships, communication and negotiation are what’s needed and GPs are already skilled in those.’

Dr Marshall concedes that there exists a group of GPs opposed to the changes who could conceivably try to obstruct the reforms and he suggests the new GP contract should include ‘levers’ such as aligning financial and clinical accountability, to force those who insist on dragging their feet into line.

But, he says, the vast majority of GPs like doctor A could have a beneficial effect on the new system: ‘There is a big group of GPs who are naturally cautious and for good reason. They are asking good questions and helping the more enthusiastic GPs temper their ambition.’

Doctor B

The white paper and its cast of supporting consultation documents make it clear that there will be opportunities and incentives for GPs to take on expanded roles. To some extent the GP-led commissioning consortiums will take the place of PCTs, giving individual GPs unprecedented scope to direct provision of care.

Aside from taking the lead at practice level, GPs could conceivably choose to become the accountable officer for their consortium, assuming legal responsibility for overspends and underperformance but taking direct control of the direction of travel for dozens of other practices in their region. There are also likely to be roles for GPs in overseeing groups or federations of like-minded consortiums and even potentially at national level in the new NHS Commissioning Board which will oversee the consortiums themselves.

Dr Jenner has a tongue-in-cheek vision of how doctor B will fare under the new system. Expressing his own views, rather than those of the NHS Alliance, he says: ‘With a view to provoking debate and identifying the challenges, I’d say that by 2014, doctor B will be heavily engaged in new consortiums and will be spending less and less time with patients. He will still have the enthusiasm to make a difference but will be beginning to feel frustrated with doing the work PCTs used to do.

‘It won´t be a uniform picture. He will genuinely be working with secondary care consultants but will be feeling frustrated that Monitor is challenging him to run open tenders for services he feels could be provided within general practice by specialist GPs and specialists.

‘He will have had some early successes reforming referrals but will still be finding hospitals charging him more and more. Meanwhile the Daily Mail will be taking pot shots at him for failing to deliver!’

Whether doctor B faces years of mounting frustration or a future of unfettered power as some commentators would have us believe – or perhaps both – Dr Marshall suggests such GPs will need to have their feet on the ground if they are to succeed: ‘They will have to know their area, their patients and their general practice. This will give them credibility among other GPs, which is essential and will enable them to listen to all the relevant voices locally.’

Some of the so-called alpha GPs who have emerged in recent years could have senior roles in consortiums, but Dr Marshall believes that new types of GP leaders could emerge.

‘Are the alpha GPs we’ve got now going to be the ones of the future? We’re creating a new environment and that itself may create a new sense of clinical leadership – we could see new types of leaders emerge once they are properly developed and remunerated as part of their day job rather than people doing things on top of their normal workloads.

‘You don’t necessarily need lots of entrepreneurs. If you’re working basically with needs, resources and outcomes, that puts the entrepreneurial ball back into the provider’s court.

‘Ideally the gap between doctor B and doctor A shouldn’t become too big. The worst thing that could happen is that the enthusiasts rush ahead of the rest or if top-end GPs see themselves as being able to tell everybody else what to do.’

But Dr Marshall says he foresees huge opportunities for doctor B under the reformed NHS. ‘There will be opportunities at consortium level, in federations, perhaps in the NHS commissioning board and – if we make this work – even on an international level. If it works, we’ll be the envy of the world.’

Alisdair Stirling is a freelance journalist

Pen-portraits of two stereotypical GPs

Doctor A

Doctor A has been largely trying to avoid commissioning until now. He sees himself primarily as a GP who wants to concentrate on the day job of seeing patients and is concerned his GMS income may now come to depend on his commissioning involvement. There is another partner in his practice who is the ‘commissioning lead’ and the practice has been a consortium member but has not actually spearheaded any service redesigns.

The GP lead sometimes points out how well the practice is doing on a particular referral bar chart but it is all done on a casual, informal basis.

Doctor A is hopeful the commissioning lead can still be the one to absorb the new policy while he focuses on the more clinical areas within the practice.

Doctor B

Doctor B is what has become known as an alpha-GP. He prints off the practice spreadsheets and knows off the top of his head how the practice compares with others within the consortium on big referral areas. He is on first-name terms with the LMC chair.

He is keen to start providing more services under the changes and is already a managing director of a local pain management service that other consortium members refer patients to as the service is on Choose and Book. He is an executive board member of a consortium that has already shown it is able to save £200,000 through tackling COPD admissions alone.

His practice partners see doctor B as a bit of a maverick. While they are grateful for his commitment to commissioning and his entrepreneurialism, they see themselves as a bread-and-butter GP practice and do not share his provision ambitions.

Doctor B’s concerns are about the few practices in his area that now look set to join the consortium. He is worried these ‘outliers’ will put a strain on the budget as they refer a high number of patients.