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Serious questions behind the nervous laughter


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Friday, 2 July 2010

Serious questions behind the nervous laughter

You really had to be there, but when Sarah Montague asked Andrew Lansley what the Treasury thought when he announced plans to hand over £70-80 billion to GPs, it got one of the biggest laughs of the Confederation conference.

Of course it’s not funny at all. The reaction was the nervous response of PCTs who know what GP commissioning means for NHS managers and the nervous laughter of GPs who are beginning to consider what it mean for them.

There are at least five big questions raised by the policy.

1. How will financial governance be managed? It’s hard enough to keep 151 commissioning organisations solvent. GP commissioning is going to create at least three times that number of commissioning groups.

2. Who will carry the risk? What happens if a GP group runs out of money two-thirds of the way through the year? What sanctions can be applied to a defaulting GP group? And if you think you have an answer, try asking the same question with the word “realistically” somewhere in it.

3. Do GPs want to be commissioners? We know that GPs already make commissioning decisions in every act of referral and prescribing. There is a world of difference between this passive commissioning model and deliberate acts of commissioning that ask GPs to weigh their own financial interests against medical ones.

4. Are GPs ready to be commissioners? This is not just a question of disposition or motivation, but of expertise and training.

5. Is the GP commissioning label a missed opportunity? Hospital doctors, pharmacists, nurses and allied health professionals need to be part of the commissioning process if the full range of expertise is to be brought to bear on the needs of patients. GPs play a pivotal role but not the only role.

Against these questions, you have to set one even bigger one: what other option is there? General practice (rather than practitioner) based commissioning makes too much sense to ignore. The GP list is a well-defined and manageable unit of population.

More importantly, the practice is the only place to start building a truly patient centred model of care. Care pathways start with local information and care management. The questions may show up in the regional data but the answers need to be worked out between the patient and the GP.

The commissioning information available to GPs isn’t available anywhere else in the system. It isn’t data but local knowledge that will deliver the benefits of QIPP, more effective interventions, improved safety and quality of care.

Nobody disputes that the destination is right, so it would be a travesty to let the difficulties of the journey derail GP commissioning.