As Pulse recently highlighted, it is now very obvious that on many CCG boards GPs are not even in a simple majority. Yet supposedly the greatest change under the new Health and Social Care Act was that GPs would lead the NHS.
Are grassroots GPs really involved in commissioning? Or is it still an old boys club where the few who have always been active remain at the forefront, along with management? The answer in most places seems to obviously be the latter.
Clearly, widespread apathy is a major factor as we saw in the pensions action fiasco too. Some feel that GPs are being made scapegoats by being put in charge of commissioning in the current economic climate.
Despite this, one of the most important factors is the capacity of practices to allow their workforce, mainly GPs, to go out and engage actively in commissioning-related work. Most practices are already burdened with increasing demands on their time by an array of organisations, whose names constantly keep changing.
Evidence suggests that not only have the number of consultations per patient risen significantly over the last decade, but that GPs are providing increasingly complex treatments as well.1 The Office for National Statistics suggests that the proportion of elderly patients have risen and will continue to rise.2 Hence, the complexity and burden of an ageing population can only head northwards.
QOF managers ask us to do more every year to achieve the same reward. We are increasingly expected to refer less, reduce admissions and reduce prescribing budgets. At the same time, the unfair and disproportionate pension reform inflicted on the profession does not improve a discouraging picture of the future of general practice.
It remains an indisputable fact that practices do not have any spare capacity to proactively and meaningfully engage in commissioning. In many areas, the remuneration for CCG work does not even cover the cost of a locum, which has soared dramatically and has become difficult to organise as the locum workforce has dwindled. Remuneration rates vary widely, as highlighted by Pulse in the past.3 In deprived areas like ours and many others, even finding good salaried GPs is a big problem – it is extremely difficult to attract candidates into areas that have been highlighted in the report GPs in the deep end.4 Unfortunately, these are the areas where clinical leadership can make the biggest difference.
Many of our colleagues rely on a few enthusiastic GPs to work for CCGs out of their own goodwill. But we hardly have any of these type of doctors left, given how overstretched we are.
Hence, many practices – especially small or single-handed ones – find it extremely hard to have their voice heard, while other practices end up having inequitable and excessive involvement in commissioning. Both lose at various levels.
If you really believe that putting GPs at the very centre of commissioning creates efficiency and innovation in the system, it is grossly short-sighted to discourage practices and GPs from becoming involved – whether because of inadequate capacity, remuneration or both. These problems affect partners, true, but they are also particularly off-putting to salaried and sessional GPs. Engaging GPs across the board was supposed to be the whole point of commissioning and, as the saying goes, you are unlikely to get different a dish from the same recipe.
It is high time that CCG leaders started to look at workforce planning to create capacity for GP engagement. It may be that CCGs need to employ extra workforce to help practices cover the lost time. It may be that practices start to get equitable involvement with support. I understand that it is sinful these days for GPs to ask for any pay increase, but it is only fair to ask for appropriate remuneration to reflect the time committed to commissioning as a partner – or sessional doctor, or locum. The NHS Confederation, it must be said, has already called for this.5
It is also time for our colleagues to stop expecting us to work on commissioning out of pure goodwill. This expectation risks losing our trust. As was the clear emerging theme from the LMC conference this year that 'no new work without new pay', it is only fair that we stand our ground at all levels.
Dr Kamal Sidhu is a GP in Peterlee, Durham and is involved in commissioning work in his locality
1. NHS Information Centre. Trends in consultation rates in general practice, 1995 to 2006: analysis of the QRESEARCH database. 2007.http://tinyurl.com/cghebo3
2. Office of National Statistics. What are the chances of surviving to age 100? 2012. http://tinyurl.com/cwdwa3r
3. Iacobucci G. GPs expected to do commissioning group work for free. Pulse 2011, online 30 September. http://tinyurl.com/ccvoxc6
4. University of Glasgow. General practitioners at the deep end. 2009. http://tinyurl.com/c3rkxle
5. NHS Confederation. Deciding how to pay: remuneration for clinical commissioners. 2012. http://tinyurl.com/bp6wb75