If the NHS is difficult for members of the public to access and understand, then what is proposed for GPs offers a further level of complexity. Put simply, they are being asked to commission (buy) services from hospitals and other health care providers on behalf of their patients. GPs should be good for this role because they are close to their patients, understand their needs, and appreciate the complexity of services offered.
Yet these positive attributes will also make it a real challenge for GPs to take on this commissioning role. Let’s understand first their role in general practice.
What many members of the public don’t fully appreciate is that GPs are small business entrepreneurs. They are private contractors selling services to the NHS and therefore have a keen eye on their profit, the use of their limited time, and the quality of what they offer their patients. Theirs is a micro perspective, dealing with patients that come through their surgery door.
GPs therefore have to run their surgeries very efficiently, and because of their targets and how they are paid, they need to align what they offer patients with the income they receive. Commissioning could not be more different. Think about oil and vinegar.
Rather than running a small business, they will have to take in the big picture across the whole community. Instead of individual patients, they’ll be dealing with a complex set of inter-relationships. And rather than carrying out tasks in the surgery, GPs will need to think about the priorities of the whole community, how patients move through the system, and how they improve services to patients.
Many GPs want to take on the new role; others rightly want to remain in their surgeries. For those who want to lead clinical commissioning groups (CCGs), there are three key challenges they have to tackle in order to make this upheaval beneficial for their patients and communities.
First is to take a strategic perspective. They will need to raise their eyes up and look at the whole system they either control or can influence. This is not just within their NHS budget, but beyond. Take for example mental health. The costs the NHS incurs are one thing, but the wider human costs and output losses can be over four times this amount.
Taking a long-term, total cost view will enable GPs to make a step change in mental health service design and delivery. After all, they see these problems first-hand through the disproportionate number of their patients with mental health issues, so it is only logical to tackle this at the community level.
Second, GPs will need to engage, influence and motivate a wide range of stakeholders. There are the practices and partners in their own CCG, with a focus on improving quality, reducing variation, and maximising spend.
Tackling their colleagues who provide poorer quality services will be paramount. Then there is the range of providers they will have to convince to change their ways. This will not be easy, especially those hospitals that think they rule the roost, and might be regarded by some as “too big to fail”.
There is also the engagement of patients, communities and the general public. This is where GPs can really score. They’re the closest to patients, and a realistic explanation about the pros and cons of certain services, be they community hospitals, maternity services or A&E, will go a long way to stripping away the veneer of public ignorance about quality, safety and cost.
The third challenge is to redesign services. The NHS is still a hospital-driven illness service, so changing the balance is like turning around the supertanker.
However, GPs owe it to future generations to change the emphasis to improve health rather than just cure illness. Telemedicine and other technologies can offer patients greater control of their treatment outside hospital. As trusted professionals, GPs have the opportunity to unhook the public from its obsession with bricks and mortar.
GPs have it in their grasp to meet these challenges and improve the quality, location and type of services provided to patients. However, this new role will not be for all GPs. For those who want to become commissioners, they will need a lot of on-the-job training and development, and bring the best of their entrepreneurship to the new role.
So GPs can be the right people to lead commissioning. But if they’re not successful in making this transition, then, to paraphrase George Lucas, the Empire will strike back.