Yesterday I posed the suggestion that one of the main problems for NHS commissioning was the split between the practicality of doing the commissioning and the strategic level of planning. The standards of plans varied between ‘OK’ and ‘very good’ but for some PCTs the use of their powers and capacity of their commissioning to put those plans into effect was very minimal. Commissioning, in a number of places, simply meant handing out the money to the same providers as last year plus or minus a few percentage points. This continuation of past commissioning activity took place even where there was recognition – in the plans – that radical changes to health care were needed in the locality.
The best PCTs had actively brought their GPs into the commissioning process because they recognised that they were involved in the day to day business of referring patients. As a consequence they realised that in order to meet their patient’s needs, health care needed to change. Commissioning would provide GPs with a new engine to bring about those changes.
The idea was that because GPs essentially had a very practical day to day relationship with their patients this strong practicality would inform and create new power for commissioning intentions.
This was of course the basis for the coalition government reforms to create a whole new system of GP led commissioning.
If we fast forward to this summer and the creation of Clinical Commissioning Groups we can begin to see how well this new infusion of practical experience into commissioning might begin to work.
I only have limited experience of a few GPs leading a few commissioning groups, but whenever I talk to them about wider commissioning activity they bring up very specific cases from their practices. These examples usually contain strong evidence where the existing system of care in their locality is not working at all well. We then, in discussion, build on that experience to think through how a different commissioning intent might bring about different outcomes for their patients. Often this is not straightforward, but basing a possible new way of providing health care on real cases is probably better than basing them on hypothesis.
However for much of their time this summer these same GPs are investing a lot of their energy in leading their organisations through the authorisation process which, if they are successful, will provide them with the opportunity to commission for their patients.
The first wave of 35 CCGs going through this process has now been announced.
Today, July 3, they will submit their applications for authorisation.
The authorisation process has 138 domains that the CCGs need to address. The supporting documents demonstrating capacity, knowledge and competence in those 138 areas would – so one CCG informs me – be about 6 feet high.
Going through this process is not only hard work, and pretty all consuming, but is some considerable distance from what these GPs signed up for. GPs that have come into this process because of their practical experience of health care are confronted with a process that is rigorously abstract.
It acts as a very powerful ‘rite of passage’ since you have to want to commissioning services for your patients quite a lot to be prepared to spend your summer working through this maze of abstractions.
Luckily for some of them consumed by this process there are ex-PCT staff around with experience of the world class commissioning assessment that took place between 2007 and 2010. They are wheeling out similar answers to slightly different questions about organisational competency that they used in the past for the PCTs.
All of this detail will now be read by management consultants and will provide a set of questions for visits in September to decide whether the CCG will be given the right to commission – or whether the National Commissioning Board will keep some of their powers back.
I’m not sure this is what the Secretary of State had in mind when he started this process.
I’m pretty sure it wasn’t the activity that GPs had in mind for their development this summer either.
There are other practical problems lying alongside the authorisation process (btw, the timescale for this is incredibly short, with ever-changing demands which adds to the problems): lack of information on actual functions.
For instance, we have only just heard that GP IT will be the responsibility of CCGs, but premises will remain with the NHS CB LAT (Local Area Teams): I hope – but don’t expect – that adequate funding will accompany this.
When requirements and responsibilities are changed less than 9 months before the CCGs become statutory bodies, the time demands on participating GPs will be significant (which is a matter involving practices – and patient access – as well as the individual), is it surprising that there have been a number of high-profile lead GP resignations from CCGs already?
Even GPs have yet to discover how to be in two places at the same time!
There are 6 domains. The authorisation work is being done 95% by PCT staff, GPs would not know where to start with most of it.