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Should CCGs performance manage GP practices? No


Having CCGs performance manage practices will only alienate GPs, says Dr Michelle Drage

Most GPs do their best, and punishing them for missing ‘targets' will only alienate them. Every cat owner knows that if you want to keep your cats away from the cream, you should give them a mouse to play with.

Every student of NHS behaviour knows that if they want to keep GPs away from the real money and influence, give them performance management of their GP colleagues to play with.

And so the prospect of CCGs ‘doing performance management' of their members, as well as ‘doing commissioning', risks turning the culture of CCGs into that of PCTs – the very bodies the health act was designed to abolish. For on the back of a single clause in the largest-ever act, just one single reference to improving the quality of primary care (note it doesn't say general practice) may be about to become CCGs' first and overriding duty.

But what actually is performance management? Is it a positive and supportive system underpinned by a strong culture of education, training and development, properly resourced and incentivised? Or is it a negative and punitive regime, based on the threat of sanctions and contractual action?

Evidence for the supportive approach extends as far back as the 1980s and 1990s, when family practitioner committees were enabled to pursue such cultures. This delivered a GP and practice nurse workforce motivated to radically improve what practices offered in clinical care – from asthma, diabetes and high-quality general practice to improved premises and primary care team growth. Such motivational cultures add huge value to service delivery by playing to the strengths of individuals' professionalism.

By contrast, negative, punitive performance management stresses, demotivates and burns out many GPs, undermines professionalism and often misses targets. It subjects those who would otherwise have improved under a supportive approach to a career of endurance rather than pride in what they could achieve.

Nobody could be more supportive of CCGs seeking to promote a system of positive performance support than myself, but promoting support does not appear to be the latest Department of Health direction of travel.

Statements like ‘the functions of a PCT have to go somewhere, and CCGs are the only place left' are heard frequently. They fill me with trepidation. Surely many of the functions of PCTs could be binned to reduce bureaucracy?

Another frequent comment is: ‘Someone has to performance manage GPs…' Well, do they? Where is the evidence this works? What are the skills required, where is the training and to whom will the CCG performance managing GPs be accountable when it messes up the wrong colleague's livelihood? Then there's the latest excuse for promoting a negative approach: ‘You can't commission good secondary care services if you don't put your own house in order.' Oh please.

Sometimes the messages get muddled. ‘Peer pressure will lead to change', for example. In my book, it's supportive peer review that leads to positive change. Peer pressure often doesn't. The way to motivate peers is to provide intelligent information about outcomes and support them to navigate through the plethora of evidence to make sound clinical decisions. Success does not come by threatening professionals, funding-removal arm-twists or contractual compliance regimes.

Some say CCG performance management is okay because the contract is held by the NHS Commissioning Board, which will ensure there will be no conflict of interest. How so? From where and whom will the board get its referrals and intelligence? Others, including CCG lead colleagues, ask: ‘Who are we to stand in judgment of our colleagues' clinical practice?' As if we haven't got enough to do.

Must we accept that there has to be a punitive regime for the majority to prevent patients from suffering at the hands of the few? GPs do not go into practice to do harm – the majority try to do good against the odds. In London, our survey of practices just this week shows that nearly 80% of respondents are worried about being performance managed by their CCGs. That speaks volumes – I hope our CCG colleagues hear it.

Dr Michelle Drage is chief executive of Londonwide LMCs