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Thoughts and opinion from the wards
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Commissioning: my hopes and fears
I'm a commissioning ostrich. My views are informed by Radio 4, local meetings, Local Medical Committee briefings and medical media, in that order of impact.
If asked to balance my hopes and fears for commissioning, the scales would tip heavily towards "fear". But are my negative feelings rational or are they the product of laziness, ignorance and fear of change? Broadly, arguments in favour of the proposed changes seem to be cut costs and tailor services to local needs. All GPs will have to be part of a consortium by 2012. We will apparently be “held to account” for our contribution to the group’s commissioning performance-whatever that means. We’ll probably get a management fee for participating. There will be no “profits from surplus” to be shared around. On the plus side, we won’t be personally responsible for losses. A commissioning board will allocate practice level budgets which will be pooled in the consortium. The board will commission services which fall outside GPs’ core contracts. So Primary Care Trusts will be abolished and the commissioning boards will take over their role. That means patient allocations services, prescribing advisers, GP appraisals, and a host of other roles we take for granted. There will be no interface between us and the patients. Rationing and cuts will be blamed on us and we will have nowhere to hide. We can blame the commissioning board, but patients will know-and government will be sure to remind them-that, as Louis XIV didn’t say, “Le roi, c’est nous”. We will obviously have to re-employ the Primary Care Trust experts to help us. And why will the management apparatus necessarily be cheaper? Why abolish Primary Care Trusts rather than radically trimming them? But is it true that GP led commissioning boards will be better placed to tailor service provision to local needs? I'm not convinced. I may understand my population needs in suburban Finchley to a certain extent. We were great at fundholding because we only had to make decisions for our 4000 patients. But I haven’t a clue about what’s going on in the estate 2 miles down the road. And I wouldn’t presume to judge all the needs on my patch either. There may be unmet needs that I don’t know about. Or I may have a skewed idea of needs because I have some particularly assertive patients. Health care provision is surely the domain of Public Health and policy experts. They have stats and know how to use them. We’re trained to be advocates for our patients. I fear that GPs and lobby groups who shout loudest will get their voices heard in the commissioning process. A GP colleague describes his local practice based commissioning meetings which are a taste of things to come. They all turn up because we’re paid to. The chair person understands local issues, another GP is involved nationally and brings news from the big, wide world. Two people heckle. Three can be relied on to deliver spontaneous, random, unedited streams of consciousness. The rest nod, eat and nod off. When asked to raise their hands, they do. Or not. That’s democracy. You don’t need to be a Libyan dissident to know that it’s hard to achieve and fragile. In another area, a GP friend tells me the contract for Ear, Nose and Throat services in the community has been awarded to a private provider. Two NHS trusts lost out in the interviews. One worries that these NHS providers which are centres of excellence, will lose their capacity to train junior staff, attract excellent consultants and maintain their infrastructure as they lose this revenue streamSo perhaps we have a duty to forgo the luxury of being an ostrich, and get involved? Friends who have spent a lot of time as members of “shadow consortia”, awaiting transfer to power once the bill is passed, are demoralised. The politicians are fighting between themselves. The bill has become a battle of wills between the coalition partners. Excuse me if I don’t give up my time with the family –or new box set of “The Killing”-while they squabble and brawl Dr Ann Robinson is a GP at Mountfield Surgey in Finchley, London
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