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Planning ahead

On a home visit, our diarist reflects on how GP commissioners are perfectly positioned to commission care for the individuals they see.

The story so far

Dr Peter Weaving is a GP and locality lead in the commissioning cutting-edge area of Cumbria. An unashamed enthusiast for the reforms, he is nevertheless conscious that competition has less of a bite in rural areas – and that not everyone in Cumbria shares his vision. Last month, local consultants called a meeting amid growing concerns about the reforms. But for now, back to the day job….

‘People were saying he must be simple, the king, with those long silences. You could have heard a pin drop in the crowd.'

I was at the home of a retired statuesque nursing officer who was meandering from her account of how she was managing her increasing breathlessness from metastatic lung cancer. She was putting her affairs in order, making plans and getting the best from her remaining time. Part of that was seeing the films she wanted to see. The King's Speech was one because she remembered as a small girl walking from her home to the Market Square in Carlisle, where loudspeakers broadcasted George VI's faltering performance.

While Rebecca reminisced, my mind was wandering too. I was thinking about where we were going with our role as commissioners. Unions, colleges and learned institutions have bombarded us with criticism of the proposed reforms.

To me, the most important part of those reforms is putting a clear clinical stamp on service commissioning and design.

I considered Rebecca and her illness, its presentation three years ago and its causation perhaps 40 years back. I think about the network of services she has needed that cover everything from smoking cessation to screening, from bronchoscopy to immunocytochemistry and now domiciliary oxygen to domestic support. Your role as GP commissioner is to bridge the gap between the best specialist technological care, which bought her three good years and, now, simple support to get her upstairs to bed. It is for you to ensure that Rebecca gets both, delivered when needed. One of your challenges will be how to influence your budget's division to cover items as diverse as photon beam therapy, commissioned on a regional or even national level, and generic domiciliary care, which you may commission using a shared budget with social services.

In spite of the naysayers, you, in your role as a GP rather than a commissioner, are perfectly placed to see and understand how all these things have a place in the care of your patients. When you put your commissioning hat on, you take the challenge to deliver care within a finite, fair-shares budget and never utter the words: ‘We just need more resources.' The resources are already with you – it is your job to distribute them and make them go further. You may consider how you operate in a system with annual budgets when you want to invest in preventive measures that might have prevented Rebecca's cancer, but whose benefits may not be seen for decades.

‘And then there was Lord Haw-Haw's wife. She lived a few streets away. We used to go round and stare at her because she wore trousers.'

Rebecca paused and looked at me as if reading my mind. ‘And the hospice, don't forget that, because I will need the hospice.'

Planning ahead