The health white paper, Equity and Excellence
– Liberating the NHS, announced a revolution that will place
GPs at the heart of healthcare. GPs have been calling for
this for more than 15 years and, now that it is set to
become a reality, I have no doubt that GPs will rise to this
new challenge.
Of course, there is no such thing as an easy revolution –
the one thing that all revolutions have in common is that, for
better or worse, the landscape will undergo a fundamental
The health white paper, Equity and Excellence
– Liberating the NHS, announced a revolution that will place
GPs at the heart of healthcare. GPs have been calling for
this for more than 15 years and, now that it is set to
become a reality, I have no doubt that GPs will rise to this
new challenge.
Of course, there is no such thing as an easy revolution –
the one thing that all revolutions have in common is that, for
better or worse, the landscape will undergo a fundamental
change. In this case, GP-led commissioning will place control
of vast swathes of the NHS budget into the hands of GPs
and GP consortia, and it is fair to say that this is an equally
exciting and daunting prospect.
The role of the Royal College of GPs (RCGP) is clear:
we must support our members, and equally, our patients,
and ensure that the implementation of these revolutionary
proposals does not denigrate the role of the generalist, or
the quality of care that they provide.
Since the paper was released in July, we have worked
closely with our members, through consultation, to identify
their concerns and to offer solutions in the form of official
response to the Department of Health. In addition to this
we have, and continue to implement, a programme of work
to ensure that our members are fully prepared to meet the
expectations of this “new” health service.
At the heart of our programme of work is the new RCGP
Centre for Commissioning, which will launch in December.
The centre, developed in partnership with the NHS Institute
for Innovation and Improvement, will be integral in
helping GPs and emerging GP consortia develop the skills,
competencies and expertise required to deliver effective
service development and clinical leadership. It will aid
primary care in the creation of efficient and effective systems
that will in turn deliver good value for money, and, most
importantly, improved patient outcomes.
The college is uniquely placed to lead on clinical
pathways, development of education and training for
commissioning, helping emerging consortia deal with
variation in practice, and supporting work on quality
and standards in emerging federations. The RCGP has an excellent track record for education and quality improvement; the NHS Institute unrivalled NHS experience.
Our aim is to draw on the proven relationship the college
has, not only with GPs, but with others in primary care
to take a unique position in the commissioning arena.
To achieve this, the centre will deliver a diverse range of
resources to help GPs and emerging GP consortia manage
the challenges of commissioning, as well as delivering
training material that is congruent with the values and needs
of busy GPs.
The centre will be integral in helping GPs and emerging
GP consortia develop the skills, competencies and expertise
required to deliver effective service development and clinical
leadership, and will provide a range of proven, cost-effective
and best practice solutions. This will help improve not
only the quality of commissioning but also the capability
of members to engage in the commissioning and qualityimprovement process.
Demand management
One of the concerns raised by many of our members
following the release of the white paper was that
their workload would increase exponentially with the
implementation of these commissioning proposals. All GPs
have a right to know what these changes will mean to them,
and what new demands GP-led commissioning will put on
them professionally.
Our message has been clear: the majority of GPs will
be able to continue working as they have before; what is
important is that they consider commissioning, as they have
always done, in their daily work. Practical involvement in
commissioning boards will be undertaken by a small
percentage of GPs as part of consortia.
GPs are hopeful for the future, but they also have realistic, justifiable concerns regarding how the face of this revolution will change in the light of the economic climate. It is a real possibility that this vision of placing GPs at the centre of commissioning could be undermined by the realities of the financial constraints and budget cuts we all face. The college will do whatever it can to ensure commissioning does not become about corporate power and control, but remains about the promotion of clinical judgement and collaborations.
The white paper has placed a number of new demands on
GPs, but facing them must not come at the cost of the role of
the generalist, or at the cost of high-quality care. Contracting
is complicated, but we must protect the role of GPs in
providing commissioning, and guard against a shift in power
to external organisations. This is something that is already
happening, and emerging consortia are already aligning
themselves with external companies.
While external organisations can add value, it is unwise to
assume that they will by default be cheaper and at a higher
quality than existing NHS managers. Robust systems must
be put in place to ensure that quality is not sacrificed at the
altar of cost, and that budgets outweigh the importance
of care provision. Whatever happens, we must ensure
that commissioning remains rooted in the promotion of
clinical judgement, addressing health inequalities, quality
improvement and collaboration.
GP-led commissioning will depend on professional dialogues between primary care clinicians, our specialist colleagues and social care providers, working together to design services that best meet the needs of our patients. It will also will also depend on strong leadership, both now and in the future, and it is one of my personal missions to support the new cohort of doctors, Associates in Training and the First5 doctors in developing the necessary leadership skills to take on roles in future consortia.
To assist, the college has published our Update on Commissioning Activity, in which we have established 10 key
principles that any commissioning body should adhere to,
such that patients and the public continue to receive highquality, free and universal healthcare. The real work begins
in ensuring that these principles, which are at the heart of
everything we do, are practically applied.
New territory
The difficult reality of the situation is that this is unchartered
territory and, principles pertaining, we cannot judge the
success or failure of GP-led commissioning until we see it
in action. How we define success or failure, too, remains to
be defined. It is so important that we do not equate poor
commissioning performance with poor GP performance;
we are, after all, living in financially stringent times. As the
funding crisis bites, there is an all-too-real risk that GPs will
be blamed for overspends, that this will be translated as
“poor GP performance” and that commissioning consortia
will respond by restricting referral and prescribing freedoms.
If the success of GP-led commissioning is to be measured
in a reduction of A&E attendance or of the number of
patients on statins, rather than a real, tangible improvement
to the general health of every member of society, rich or
poor, young or old, then this new order will have failed.
Good commissioning is about being a good GP; whatever
we do must be in the best interests of our patients, and
delivered in a safe and high-quality way. It is about ensuring
that GPs understand their role in demand management,
in maintaining the highest possible standards of care, and
above all, it is about the primacy of the doctor-patient
relationship.
It is my duty as Chair of Council to support, and also
shape, these proposed reforms. The college is committed
to protecting the role of our members, and to protecting
the NHS as a universal service, free at the point of use from
“womb to tomb”.
General practice has a hard-earned and well-deserved
place at the forefront of the NHS, and I will work tirelessly
to ensure that we are able to continue providing excellent
generalist care, delivered in the heart of the communities
we serve.
