Leading GP commissioning

Local picture

Mid-Sussex has 16 practices, covering a rapidly ageing urban and rural population of 144 000 across East Grinstead, Haywards Heath, and Burgess Hill. It is one of three GP commissioning consortiums (GPCCs) in the North West Sussex Commissioning Association. All three have been actively involved in the forerunner of the new GP commissioning, practice based commissioning, from the start, developing community services in areas such as cardiology and chronic obstructive pulmonary disease and a referral review scheme.

Despite this history, Dr Patel admits there were mixed attitudes to commissioning on his patch before the white paper, Equity and excellence: Liberating the NHS, was published in July 2010. Some colleagues were “apathetic.”

While he wouldn’t claim every GP is on board now, there has been a dramatic change. “There has been a lot of positivity with people volunteering for pieces of work. They accept that there is a responsibility coming their way and they want to know what part they will play.”

Bringing people along demands communication and persuading them that GP commissioning can tackle the problems with patient care that frustrate them every working day, he says.

But there are still very real concerns. “People fear being lumbered with the largest financial deficit in NHS history while being accountable for delivery against a budget for the first time, in an environment of shifting responsibilities—with the largest cut in management costs ever.”

Time commitment

Dr Patel warns that GPs who want to play a lead role in commissioning must not “underestimate how much time is involved.” He is a full time partner at Moatfield Surgery in East Grinstead. In theory, he devotes 1.5 days a week chairing the GPCC. It is rarely that simple, however.

“I shoehorn meetings into the clinical days frequently,” he says. In reality, he works around 35 to 38 hours at the surgery and 17 to 21 hours on commissioning.

Recently whole days have been taken up holding interviews for posts in the new county-wide commissioning support team and contract support unit. Most weeks there are two evening meetings to attend, and another two evenings are spent working on documents, making phone calls, or handling the 40 to 60 emails he receives about commissioning issues every day.

“It would seem that my life is dominated by meetings and emails but I am switched on to the need for delivery and try to ensure that everything I do is purposeful.” Weekends are reserved for his family. “I try not to look at emails or work but occasionally will read the odd document.”

On top of this there are visits to the member practices. Dr Patel aims to visit each twice a year, “meeting people I don’t normally come across, building relationships and seeing what their working circumstances are like.”

GP roles

There’s no magic number of GPs who have to be involved in consortiums to make it a success, says Dr Patel. It will vary from area to area. But GPCC can’t just be left to a few enthusiasts.

“Typically you have someone like me who lives and breathes this stuff but we need a very broad group of people who are keen to lead on particular areas of work in the locality.”

He estimates 17 of the 90 GPs in his group are actively involved in commissioning. Four are GPCC board members, a further six each take the lead on projects, while seven others attend meetings regularly.

Staying grounded

It’s vital that commissioning leads are working GPs, Dr Patel says. The two roles are independent, requiring different skills, but feed into each other. “Being a coalface GP ensures I remain reasonably grounded, understand the problems patients and professionals face, the practical challenges ahead and practical solutions.

“Seeing things from a GPCC perspective does make me think about patient pathways, systems, people in the system, resource use when I am seeing patients.”

Relationships

Much of the job is about building relationships with the wider NHS outside general practice and beyond. County councils will have a key role under the reforms, holding GPCCs to account and taking over responsibility for public health. This means “meeting, sharing aspirations and expectations and then getting into a little detail on what delivery structures look like and how people are involved, agreeing accountabilities and responsibilities.”

Dr Patel says you have to be open to advice from outside your own immediate team. “It would be easy to think you are always right but the politics of commissioning are complicated and you have to be open to ideas.”

Support from organisations such as the Royal College of General Practitioners, NHS Alliance, and National Association for Primary Care can be enormously helpful to develop new skills, competencies and capacity, he adds.

You need to work closely with your primary care trust—in his case, NHS West Sussex. “In the NHS we always think that people who have done the job before reorganisations must have done it badly but there are an awful lot of good people in PCT [primary care trust] land.” And GPs aren’t always aware of the full range of statutory responsibilities and activities that PCTs carry out—there’s a lot to learn.

Financial pressures

GP commissioning means family doctors will be responsible for making “efficiency savings” on an unprecedented scale. In North West Sussex that means cutting £18m every year for four years, thanks to the double whammy of the move to fair share budgets and central demands for efficiency savings.

“PCTs have concentrated on growth and not been too concerned about how the money is spent as long as things weren’t going too wrong,” Dr Patel says. “Our health economy has been driven by supply not demand—if you have services they get used.”

The three GPCCs face “significant issues on our patch, with our acute and community providers.” They will have to manage contracts with two large acute trusts, Brighton and Sussex University Hospitals and Surrey and Sussex Healthcare; the Queen Victoria Hospital Foundation Trust in East Grinstead; an independent sector treatment centre contract; and the Sussex Community Trust and Sussex Partnership Foundation trust for mental health services.

A new commissioning support unit covering the whole county will help with contract management, under a service level agreement with the GPCCs. It will be staffed by 12 to 15 managers transferred from the old primary care trust. Two will work for Mid-Sussex GPCC.

Issues the three consortiums must tackle include caesarean section rates that are “well above the national best quartile,” which means redesigning maternity care pathways.

But acute financial pressures cannot be handled by service redesign alone. Dr Patel believes his group will have no choice but to stop funding some procedures.

“I am not suggesting we could do anything outside legislation such as introducing charges or limiting services in an unethical way, but between the public and the professionals we need to have a dialogue about what is a core NHS service.”

Decommissioning entire services is on the agenda. “If you have three large acute trusts on your doorstep, all doing the same thing, are those services sustainable?”

Care may well need to be centralised on fewer sites: “The public get very aerated about losing A&E [accident and emergency] or maternity services—but we are in unprecedented waters financially.”

Future challenges

The introduction of GP commissioning is a radical change. The scale of the challenge should not be underestimated. “While we have been accountable to some extent under practice based commissioning that was largely about redesigning services,” says Dr Patel.

“Now we are going to have to take responsibility for total commissioning. Clinical leadership will look very different: people will have to upskill and develop new competencies.” Responsibility for entire local health systems, taking over all the statutory duties of primary care trusts, and getting stuck into areas such as finance and managing large contracts present a steep learning curve, he adds.

But as primary care trusts disappear, GPs have little choice but to take up the challenge. “The door is being shut behind us . . . this is a one-way street.”