Editor Sue McNulty contemplates what the future means for those not yet involved with commissioning, following the bill changes.
David Nicholson's anecdote today about trying to register with a practice when he moved house has more than just comedy value. First I'll share the anecdote because it is very funny. Sir David, chief executive of the NHS popped into his local practice to register to be told there was a system and they only took patients from a certain locality.
Another patient in the waiting room piped up ‘Oh I live in his area, I'm registered here' to which the receptionist replied ‘Yes but you're a hangover from the past.'
As if the car-crash mystery shopping trip couldn't get any worse, Sir David made his case and asked to see the practice manager to be told she was in a meeting and could he come back another time.
Sir David grew a little agitated and said: ‘no, I've chosen to come here, I want to come to this practice. I've looked at all the information and this is the one I want to register with, it's my choice.'
To which the receptionist said: ‘Don't use that word, the doctor doesn't like it.'
Sometimes you need a healthy reminder of how many GPs out there – the white van man GPs who perceive themselves as very much independent contractors - are so removed from this NHS reforming lark.
Until the watering down of the bill this week we were told all GPs would have to be in a consortium by 2013. This compulsory element moved GP commissioning into very new territory. Not only was GP commissioning about redesigning services, it was about working with the outliers in your consortium and peer reviewing them. Now we're told GPs will take on commissioning responsibility when they're ‘good and ready'.
Sir David says the ‘ambition' has to be for the whole of the country to be covered by clinical commissioning groups and spoke of lots of support to help GPs get to where they needed to be.
But Dr Robert Varnam, clinical lead at the RCGP Centre for Commissioning said some consortium leaders report only a fifth of GPs turning up at meetings at the moment. Pulse's recent survey found 19 out of 20 consortium chairs wanted to go ahead with the 2013 deadline, but the same survey found less than 40 per cent of ‘grassroots' GPs felt the same way.
It looks like a gulf is growing between GPs in leadership roles and the ‘white van man' GPs who are not tuned in to the reform agenda and it will be interesting to see what happens next. For the already-converted to PBC there is a glint in their eyes. As Sir David himself said today the failure of PBC was that PCTs were required to let go of power, while at the same time being accountable for PBC groups' actions. You could have beefed up PBC as much as you like, but it would never have overcome this contradiction. Even ‘successes' like the many we featured as case studies in Practical Commissioning were often ‘one-offs' with the PCT remaining nervous and only giving a fraction of the overall budget over to GP commissioners.
There is so much change now possible but it's a double-edged sword to white van man GPs. On the one hand, there is procurement, responsibility for ensuring whistleblowing and safeguarding measures are in place by providers, EU contract law, TUPE and that was before the reforms were changed - even more layers introduced this week with senates and additional public consultation requirements.
On the other though is the chance to come out of the general practice silo and really integrate with social care and hospitals and attempt to make life better for patients. With the exception of care trusts, horizontal integrated care is pretty much an untouched area for GP commissioning. This for me is the exciting bit and where I look forward to seeing what GP commissioners can do. Last year, mental health was seen as an area that GPs would ‘leave to the experts' but because it impinges so much on their daily work – 1 in 4 consultations involves a mental health issue - there are signs it is an area being treated as a priority in some areas because GPs want something done to improve inadequate services.
Two-tierism is now inevitable with the removal of the 2013 deadline.
The question now is how to make the real pathfinders create a trail that the unconverted might want to drive down?
Editor, Sue McNulty