Should GPs have contractual responsibility for commissioning?

The huge changes ahead will only be effective with a GP contract that includes commissioning responsibility, says Dr Jonny Marshall. But Dr Brian Balmer argues that coercion might well threaten the innovation that GP commissioning could deliver

If the Government is to be successful in transforming the NHS into a patient-centred, outcome-based service, it will be critical to influence the attitudes and clinical behaviours of GPs.

GPs already commit resources within the NHS through referrals, prescribing and whichever range of services they provide. In effect, they already commission.

But at present their contractual responsibility for this commissioning role is weak.

It's widely recognised that unwarranted variation in clinical practice exists across the NHS – depending on the variation in the behaviour of the clinician rather than on patients' needs.

Addressing this variation among GPs will deliver a more predictable, high-quality, patient-centred service with better health outcomes and better financial control. In this sense the provider and commissioner role of GPs is inseparable. So this change has to be underpinned by a GP contract that contains responsibility for both commissioning and providing.

Positively influencing GPs' clinical behaviour depends on developing the right incentives to provide a powerful enough reward to gain support – as it is for all doctors. These need to cover more than one of the following four areas: quality of patient care, quality of the GP's working day, respect from professional peers and personal income.

Many of these incentives can be delivered through a variety of mechanisms underpinned by peer support and challenge – like audit and education. But we know from our experience with health promotion clinics and the QOF that aligning the contractual responsibility of GPs with the desired direction of travel is a very effective way of driving clinical behaviours.

Indeed, if we are going to create an NHS around a common purpose of delivering better health outcomes it will be necessary to align the contractual responsibility of all partnership organisations.

In order to meet the challenges of increasing healthcare demand within a finite resource, the NHS will need to become increasingly productive and balance quality, patient experience and financial control.

Under GP commissioning, GPs will need to adopt an increasingly professional role in the assessment of the needs of their population and commission services to meet them. But this will require a move away from a reactive, illness-based service to a pro-active health-based service in which the traditional gatekeeping role of the GP is replaced by a new type of professional accountability – extending beyond individual clinical action to encompass the total health experience of the registered population. Many already aspire to this truly holistic approach. No longer will GPs be restricted to being an advocate for individual patients within a system they have little hope of redesigning. Instead, they'll be able to play a part in delivering a health service their registered population needs through their commissioner role while navigating individual patients through the service in their provider role.

It seems such a transfer of authority is causing a significant degree of consternation – if current reports are not exaggerated. What's needed is a proportionate transfer of accountability to GPs as an act of enablement as much as an act of control. Aligning clinical and financial accountability in the GP contract would be key in achieving this. Contractual responsibility for commissioning would provide incentives to support change in clinical behaviours and enable the transfer of authority for designing an NHS that meets patients' needs.

If we as a profession are serious about general practice leading the NHS, it would be a significant step forward if we put our money where our mouths are and accept contractual responsibility for our providing and our commissioning.

Dr Johnny Marshall is chair of the National Association of Primary Care

I am broadly in favour of more GP involvement in commissioning. But I don't support any form of contractual commitment that could introduce an element of coercion and compulsion and might destroy the innovation and enthusiasm that GP commissioning should encourage.

GP commissioning is clearly a major plank of the new Government's plans for health and it might be a catalyst for real change and to deliver improved outcomes for patients in the difficult times ahead. The Government will be keen to implement changes to NHS commissioning, but compulsion of GPs would be a disaster.

GP commissioning must be developed on sound foundations that protect funding for primary care, allow the majority of GPs to limit their involvement to an agreed minimum, and preserve the vital role of the GP as the advocate of the patient.

A headlong rush to real budgets could jeopardise the relationship between patients and primary care, and the planned collaboration between GPs and secondary care.

Let's be clear why this is happening. Commissioning by PCTs has not been an unbridled success, and practice-based commissioning has had a difficult time in many areas. The Government wants results and wants to maximise the care and quality delivered by every pound spent. There is also a strong desire to reduce management costs.

All of this creates the momentum for GP commissioning, but the real driver for change is the economy. NHS funding will be protected during this parliament, but that still equates to a reduction of about 4% per year once NHS inflation is taken into account. If I were a politician I would pass as much responsibility to others as I could. What lunatic would choose this moment to embrace such a burden and thereby volunteer to deliver a shifting set of quality standards and outcome-based targets, all in a constantly shrinking budget?

This may be an opportunity, but it is also laden with risks. Any hint of compulsion will destroy all hope of a new way to commission. When GP commissioning arrives it will attract the brave, the bold, and occasionally the opportunistic. But that will not be enough to change commissioning to the extent required by the coalition Government. It will want to provide incentives that will attract the majority of GPs. Incentives are fine, but that is a long way from compulsion or a contractual requirement.

An incentive to take part in GP commissioning should be negotiated at a national level with the GPC. In this way the system as a whole can have the opportunity to change and hopefully become more efficient. This is not compulsion and it must be linked to realistic budgets and adequate management support. How this can be achieved while management costs are being driven down is hard to imagine. The other issue is who will commission primary care. This must be addressed or PCTs will continue to stifle innovation.

The balance of power in commissioning will change only if primary care commissioning is also changed. It is surely possible for district-wide groups of practices to monitor and performance-manage primary care in a way that satisfies patients and taxpayers and also removes the dead hand of the PCTs. Involvement of secondary care clinicians and patients would further improve such governance.

I will repeat that I am in favour of more GP involvement in commissioning, but only if practices truly volunteer for this precarious journey.

Dr Brian Balmer is chief executive of Essex LMCs