CCG: friend or foe?

Friend or foe1Put yourself for a moment into the shoes of a GP; not an ambitious, management focused, media hungry go-getter, but a doctor who wants the best for his/her patients. Your list size is average, which means that around 1600 patients are registered with you, and depend on you to co-ordinate their care, and be their first point of contact, their main provider of care.

Do you happen to know how much the NHS spends on an average GP list each year? Using the back of an envelope (so the figures are approximate), I worked out that  in 2012, the UK NHS budget was close to £110 billion, which was available to look after about 60 million people; that works out at about £1800 for each person, which meant that for an average list, about £2.9 million was available. Scary isn’t it?

Now obviously, quite a lot of this was spent on fixed overheads like Public Health England, and redundancy packages for displaced managers, but let’s ignore these for the moment, because it’s always been the Government and ‘The Centre’ that have determined these. The important point is that since April this year, control of over two thirds of this budget has been handed over to CCGs, to spend on commissioning services for their patients.

The logic underpinning this move has been explicit since the 1990s: GPs co-ordinate their patients’ care, and their referral of these patients determines much of the activity in the community, mental health and acute sectors; so who better than these individuals to ‘own’ the resources associated with all this activity, and use their knowledge, common sense and autonomous professionalism to begin to move activity in ways that improve both the effectiveness and the efficiency of that care?

All the reforms of the past two decades or more have been moving towards this end. GP fundholding, GP commissioning, PCGs, PCTs, and now CCGs, all have been designed to wrest control of activity as much from politicians as from the large provider organisations, to stop them peddling their vested interests to the public (often through the tabloid media).

The logic of all the policies developed over this time (Working for Patients; ‘a primary care led NHS’, ‘the New NHS-modern, dependable’; Equity and Excellence: Liberating the NHS; to list but a few of the buzz phrases) have all been pushing in the same direction, albeit with different structures in place to make the policies happen.

So how does this link to the title of this piece? Are CCGs a Good Thing for GPs, or a Terrible Disaster? I started by pointing out that in theory, GPs each have the power to control the manner in which £2 million pounds or more should be spent on the care of their patients, so I’ll follow that up with two challenges.  The first is: who do you think better understands patient flows and needs: patients’ GPs, or middle managers based in whatever incarnation of health authority happens to be in vogue? Only GPs know what their patients’ medical needs really are and with the freedom to be innovative, they could probably think of all sorts of ways of doing things better, more quickly, in more user-friendly ways: it’s £2 million pounds, for goodness sake…

But my contrary second challenge is about strategy: £2 million may seem like  a lot to you and me, but it’s only a couple of trees in the enormous woods of the NHS; how do we a) maximise its impact and b) minimise the risks to individual GPs, their practices, and their patients? The strength of general practice lies in individual patient care.  If GPs are to be involved in planning and procuring services for entire lists, then they will need ways of working that offer economy of scale and provide insurance against unexpected events (imagine what a cluster of motorway crashes over a holiday weekend would do to the Trauma & Orthopaedics budget) without destroying the ‘can do’ spirit that has been so integral to their success over the past 65 years.

Where CCGs are genuinely ‘owned’ by their GPs, then the new organisations have great potential.  As in any successful corporate entity, individuals will need to accept that the needs of the group will sometimes trump their own local issues, and they will have to toe the corporate line a lot more often than they may have done in the past. However, they should then expect their CCG ‘corporation’ to offer support and act on practical suggestions often enough to show the practices overall benefit and maintain their loyalty. They could then be seen as ‘friends with teeth’, where the relationship needs constant effort and development, but where the gain (whether in terms of patient care, professional satisfaction, or even primary care development) justifies the pain.

However, if CCGs are either run in a top down fashion, or driven by political rather than care based priorities, then it will not take long for the cynicism to emerge; like the PCTs before them, such CCGs will quickly be seen as foe, whose actions are to be resisted and subverted.

In summary then, CCGs have the potential to be THE agent for change in the new world of NHS England, but only if their growth and development are carefully nurtured. The large scale leadership developments that seem to be emerging from the new Leadership Academy have never worked before, so it is hard to see how they will be more likely to succeed this time. What is needed is enough interest to be engendered amongst ‘working’ GPs to persuade them to invest some of their precious time and emotional energy in getting their show on the road, and make it a show of which they, and the entire NHS, can be proud.

And that won’t happen without effort or resources; but with the potential for every GP with an average list to really influence how £2 million is spent on his or her patients, isn’t that investment worth it?

This piece is based on an article first published in Pulse magazine on 24 June 2013

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Kissing it better: beliefs in modern medicine

ImageI’m trying out a new medium today, using the University of Birmingham’s Ideas Lab, on which they’ve just posted a podcast from me about health beliefs. You can find it at:

http://tinyurl.com/nd5wql8

I think the issues are as pertinent to health care professionals as they are to patients and the public, and it’d be really helpful to start a proper discussion about ways of harnessing and influencing people’s health beliefs, rather than always trying to discount them.  Even the term ‘placebo’ now has negative connotations, rather than being seen as a useful tool in the clinician’s bag.

What do you think? Should we be sticking to the narrow and reductive route of evidence based medicine to the exclusion of all else, or is there benefit in looking at a more holistic view of healthcare that uses all the levers it can find, even (perhaps especially) the ones that reside inside our own heads?

The issues obviously matter in the determination and implementation of ‘best care’, but it may also be relevant when we consider professional knowledge transfer; how and why do professionals change their practice, and how can we influence that? Can it be done scientifically, by assuming that this week’s articles in the Lancet will translate into next week’s clinics, or is there something deeper that influences how clinicians think, how their beliefs affect their behaviour? If the latter is true, we may need to augment those scientific journals with ‘softer’, more fuzzy approaches, the kind of tools used in social marketing.

I’d be very interested in your views…

Making CCGs work: three cardinal rules

jigsawClinical commissioning has arrived, but it will take a while before it becomes clear whether it is creating order or chaos. Now may be an appropriate time to revisit the underlying principles to see how it is likely to pan out.

Commissioning is not a simple notion, but an inclusive concept that covers a number of different functions. At the ‘micro’ level, there is the direct procurement of individual services, a process that has been called contracting: the customer pays the supplier for a service on which they agree.

Let’s say the customer is a home-owner, who wants a new kitchen; he has a rough idea of what he wants (the ‘output specification’, if you like) but as he doesn’t know much about building kitchens, he will need to capitalize on the supplier’s expertise and trust him to do the job well. Success will be measured in terms of overall quality and satisfaction, timeliness, and costs, and if these aren’t met, the buyer may have to use the contract to hold the supplier to account, and gain redress for any failure.

In NHS terms, such micro-commissioning is based on GPs’ referral decisions: GPs know roughly what they want, and they have a knowledge of the local expertise; their role is to organize specific procedures with the appropriate experts, and then check that they been carried out to the agreed specification.

They have the advantage over the home-owner that their knowledge of specialist provision, whilst not encyclopedic, is detailed enough to let them make realistic assessments of quality and perception, timeliness, and costs.

At this level, one would not expect the home-owner or the GP to make decisions based on strategic impact or links to a European Directive; it would be for the specialist expert in each case to keep their customers apprised of any legal issues, and it would be the experts who would be held responsible for any non-compliance.

At the ‘macro’ level, the parallel relationship may be that between the town planners and a major home-builder; as with the individual kitchen, there needs to be agreement based on a mutual understanding of the outcome of the job, and any necessary markers of its progress.

Thus, the planners may want the new estate to be carbon neutral, to fit into the existing architectural ‘mood’, and to be completed within a certain time, to a specified quality, at an agreed cost; if they are sensible, they will leave it to the technical experts to decide the precise manner in which they respond to these specifications. Not only does that involve the builders in the decision-making and so keep them engaged and enthusiastic, it also maximizes the benefits of their expertise and promotes a degree of risk-sharing that divides up the responsibility (legal, financial, perceptual) for the project, and ensures that both parties need to attain the same positive outcome to be satisfied.

Back in the NHS, this relationship mirrors that between strategic commissioners (the CCGs, Area Teams, and the regional offices of NHS England: do we really need all three???) and the acute sector pretty well. Like the town planners, the strategic commissioners will need to incorporate national policies and regulations into their strategies. They will need enough knowledge to ensure that their providers are not pulling the wool over their eyes, without getting bogged down in the level of operational detail that boomerangs the risks back to them whilst raising the transaction costs of the whole process.

At this level, the quantum being procured is much larger, and so it is harder to ‘contest;’ a local authority, having agreed for a contractor to build them a whole new housing estate, would find it much more complex to withdraw from their contract than if they were contracting for a single kitchen. However, a competent authority should have levers to pull, should the builders not fulfill their side of the agreement.

And it is here that we come to the nub of whether or not commissioning in the NHS will succeed.

While developing and monitoring contracts (like any other performance management system) should be based on the carrots of success, it should be backed up by sanctions that are appropriate and viable.

Such levers should ultimately be based on the ability and feasibility of withdrawing the contract, something that itself depends on the availability of alternative provision and the consequences of such action (be they financial, legal, and perceptual, with the added complexity of how they affect the health of the population involved).

When the notion of commissioning first appeared the NHS in 1990 in the guise of the ‘purchaser/provider split’, its main purpose was to steer the acute sector away from fuelling ‘supply-led demand’ in health services and towards a new responsiveness to the needs of the population.

In fact, several iterations of change have not really had major impact on the acute sector, which still seems to be relatively unaffected by the current organizational changes, although it is facing some highly challenging financial pressures.

As long as it remains impractical to offer real challenge to the acute sector, commissioning will be largely irrelevant, offering no more than minor political irritation to the vast and politically-aware acute sector.

The three key challenges for the new commissioners may be summarised as follows:

– At the micro-level, the development of more widespread alternatives for GP referrals needs to be encouraged; merely shifting referrals between different hospitals won’t be enough, as the ensuing Brownian motion is unlikely to promote any real change, just random movement.

What is required is the threat of removing activity from the sector entirely, which will depend either on practices being allowed to develop viable alternatives themselves, or other providers (private or otherwise) being given access to such provision.

– At the macro-level, the systems being developed (whether through contracts or other less tangible ‘currencies’) must not be allowed to become ‘too big to fail’. Keeping the quantum of exchange small enough to allow real contestability is going to be key if commissioning is to become an effective management philosophy.

Thus for example, it is much easier to challenge the provision of a single service (Physiotherapy? Pathology? Plastic surgery?) where real service delivery changes may be seen, than in trying to shut down an entire hospital, or even parachuting a new management team into a failing Trust, where direct patient care is unlikely to be affected (at least in the short term).

– And at the ‘meso’ level that spans micro and macro, it will be vital that the consequences of any actions be seen quickly and directly. If the GPs in a CCG want to repatriate a service out of the acute sector and into the community and it takes three years and a warehouse-full of bureaucracy to do it, then the GPs will simply give up trying. The links between input and effect need to be obvious and the accountability for both needs to be transparent and appropriate.

If commissioning becomes an ineffectual brake on demand, then we may as well abandon the whole concept now; however, if we manage these cultural changes, then the introduction of the new commissioning arrangements have the potential to be the ‘pivot point’ for changing the entire dynamic of the NHS.

A version of this article was published in Pulse magazine in the UK on 8 May 2013

Why is it so hard to make soft changes?

carrotAs Robert Francis is a lawyer, he understands British legal culture, in which rules are deliberately kept as explicit as possible. Nuance cannot be the basis on which legal judgments are made, and so all the factors needed to reach a verdict have to be transparent and ‘hard’. But his final report on the mid-Staffordshire hospital crisis was wise enough to acknowledge the need for complex cultural change, and the challenge of making such ‘soft’ changes happen.

However, the actions that have emerged following the publication of his report in February seem to reflect his views less than the need of politicians to be seen to be doing something. The report may refer to the ‘softer’ less quantifiable aspects of healthcare such as ‘caring’ and ‘culture’, but the remedial steps announced so far seem to be based mainly on regulatory systems predicated on punishment and duty, not on motivation or positive intent.

Thus, the Secretary of State for Health announced ‘a new regulatory model under a strong, independent Chief Inspector of Hospitals’ and introduced ‘a new statutory duty of candour for providers, to ensure that honesty and transparency are the norm in every organisation’. Even the stipulation that nurses should spend a year as health care assistants before they take on ‘proper’ nursing seems a fairly mechanical way of changing values (as well as saying a lot about how we distinguish caring from curing, and the ‘proper’ role for nurses).

I may overuse the aphorism that ‘the floggings will continue until morale improves’, but if ever there was an illustration of its paradoxical ridiculousness, then this must be it. Concepts such as honesty, candour and openness patently cannot be forced onto staff, and so even at face value, such statements will only increase the cynicism that besets so much of the NHS.

The announcements are in themselves an important indicator of the deeper malaise in NHS leadership, where there seems to be no insight either into the manner in which the workforce functions, or into the importance of coherence between rhetoric and behaviour.

Let’s start with the workforce. Vocational occupations, such as medicine, nursing, teaching, policing, and even parenting, all depend for success on their practitioners’ professionalism. My personal definition of what professionals do, is to fill the gaps left by reductive methodologies. Once the rules have been applied, the spreadsheets completed, and the safety checks carried out, it is professional judgment that assesses the nuances and shades of uncertainty that highlight the impending disaster, the malingering patient, the struggling pupil.

The detective’s hunch and the doctor’s gut feeling are key skills, and without such professional behaviours, all the activities described above (even parenting – or NHS management for that matter) tend to lead to worse, and more expensive, outcomes.

Professionalism is the mortar between the bricks of the formal tools, holding them together, yet by definition it cannot be pinned down (or it would have been formalised into mechanical tools long ago). The systems depend on their professionals applying their nebulous skills effectively, but enforcement is nigh on impossible as the ephemeral nature of these skills means that we can’t easily identify deficiency as if wewere checking the accuracy of a temperature or the frequency of a bowel movement.

The motivated detective, keen for approval and promotion, will use his inspired hunches to brilliant effect, whereas his demotivated, burnt-out partner will stick to the rules and hide from disapproval and discipline behind an impenetrable ‘jobsworth’ shell, without actually doing anything wrong. The more we reinforce these respective behaviours, the more each detective will stick to them.

The key to successful change is to understand the factors that actually drive professional behaviour. Approval and promotion work better than disapproval and discipline. For professionals of any kind, the way to motivate them is to tempt them with increases in status, peer approval, patient benefit, pet projects, better income, and more fun in their work.

Of course, carrots need their obverse sticks, and the implicit threat of reduction in status, peer disapproval, patient disbenefit, lower income, and boring, difficult work probably all have a place in the successful management of professionals.

However, carrots work better than sticks – once a culture is perceived as punitive rather than encouraging, then motivation becomes logarithmically harder to achieve.

Jeremy Hunt’s edicts about firmer regulation and harder floggings are likely to be counterproductive, in the same way that thirty years of bullying clinicians to behave more corporately has had so little impact. Until they can understand and feel the benefit of a new behaviour personally, doctors, nurses, teachers and policemen will at best ignore or at worst sabotage each new exhortation, and feel less and less inclined to change.

The NHS is supposed to be a single state-controlled system, so there probably are important elements of corporacy that need to be developed, such as more consistent treatments, communications, and outcomes. But if corporate behaviour is important, then the way to implement these targets is by relating the desired behaviours to professionals’ own agendas. Include the clinicians in problems, involve them in their solution, ensure that the personal benefits and dis-benefits are clear, and so on – there’s a lot more to be said about this on another occasion.

However, the final point to be made is the most important. The incongruity of trying to bully professionals into less bullying behaviour will not be lost on any of the professionals working in the NHS, and the mixed message it gives them about the system in which they work means that their behaviours are unlikely to change.

This blog is based on an article published in Pulse in the UK on 22 April 2013.

On conducting orchestras and resisting magic bullets

t_WilkinsConductingThe underlying currents that have been sweeping through the NHS for the last thirty years have been remarkably simple and consistent.

Activity and costs in the acute sector had been growing too quickly for the economy to support and without enough impact on the health of the population, so two main actions were introduced.

The first was the separation of the commissioning of care (procurement, purchasing, call it what you will) from its provision, which was intended to introduce appropriate tension and ‘contestability’ and so remove any cozy collusion in the system.

The second was the strengthening of primary care (and specifically the GPs) at the front end of the system, as generalists able to treat the vast majority of illnesses themselves, ‘case manage’ the rest through their ability to control referrals to the acute sector, and co-ordinate all care, acting as the conductors of the NHS orchestra.

Mechanisms supporting these principles have developed over time, but the direction of travel seemed well established. The population quantum changed, financial levers held by primary care evolved, and the acute sector has been through its own iterations with the private and voluntary sectors beginning to become involved as providers.

The potential ‘magic bullet’ in the changes was the intention to move patients and their services out of expensive institutions. Community-based care was assumed to be more user friendly, more appropriate, more easily accessible, and cheaper, so the philosophy seemed like a ‘no brainer’.

Moreover, the drivers were strong enough to keep the GP community (more or less) on board despite repeated disappointments as the aspirational rhetoric of each round of reforms was diluted by real world politics.

What has emerged as the Kevlar vest against the magic bullet however, has been the difficulty of getting resources to follow the patients. The machinations here have been a perpetual problem that may now derail things once again.

With the reforms of the early 1990s, traditional hospital-based activity did begin to migrate to the community. Patients with diabetes, hypertension, angina, and a host of other medical conditions were treated in their GPs’ surgeries. Even some technical procedures began to move, as GP practices (or surgeons employed by them) started carrying out endoscopies, vasectomies, even more complex procedures such as hernia repairs.

However, what became quickly apparent was that the cash that could be taken out of the acute sector as it lost this activity was minimal. Individual diabetic patients only incur a few prescriptions, a modicum of staff time, and their ‘hotel’ costs. Unless one could close entire wards, real costs could apparently not be taken out, only costs at the margins. Without that incentive, the moves to make radical service changes fizzled out, leaving the established status quo more or less intact.

With the establishment of clinical commissioning (originally GP-led commissioning), the phoenix of real service change looked as if it could emerge from the ashes of previously stalled political initiative. Once again, it was proposed that GPs (or the wider primary care clinical groupings) would ‘control the majority of spending in the NHS’ and thus be able to make step changes to the dynamic of service delivery by moving resources out of the acute sector into community-based facilities.

But lo and behold, another issue has emerged to stymie these moves, based on a political ideology aimed at increasing competition, and the fear that GPs will use the new arrangements to line their own pockets. Formal competitive tendering has been introduced, whose practicalities have yet to be tested. Thus for example (according to guidance issued from the NHS Commissioning Board (NHSCB) last summer) CCGs ‘will need to decide whether services could be delivered by a number of potential providers (which may include general practice) or whether they could only be provided by general practice’. However, it is unclear how they will be held to account for their decisions, and by whom.

Although the NHSCB (through its area teams/regional offices) is not intended in principle to interfere, experience over the last two years has shown that at every stage the need to get the process right has trumped concerns about outcome. To misquote an old aphorism, we are focusing on doing things right rather than doing the right things, and this seems unlikely to change while the CB itself is learning how to function.

But there is a larger concern. The last thirty years have shown that we need to consider the structure and function of the NHS as two distinct issues. The system is evolving so that function is better and more seamlessly integrated, whilst the organizational structures that support these functions are often better kept separate. What must flow freely however, are the lubricants of success, which are money and information.

There is more discussion to be had here, but the immediate point is that as long as the funding streams of hospital and community care are handled separately, and the incentives for the preferred outcomes are not carefully and precisely aligned, no system will ever function properly. The dog’s dinner that has been the politicized process of the last three years has resulted in a confused, opaque structure that will never produce the culture that we need if we want efficient, user-friendly services as our outcome.

(This piece was first published in Pulse magazine on 9 April 2013)

The birth of CCGs: so much to do, so little time

ImageThis blog was first published in Practical Commissioning on 19 March 2013.

Although Donald Rumsfeld was a US Secretary of Defence, he will probably be remembered for a statement he made in 2002 about the Iraq war, though we’ll ignore that symbolism. Anyway, this is what he said:

‘There are known knowns; there are things we know we know. We also know there are known unknowns; that is to say, we know there are some things we do not know. But there are also unknown unknowns – the ones we don’t know we don’t know.’

As CCGs prepare for their formal birth, Rumsfeld’s aphorism is a useful guide to thinking about their developmental needs, as long as one adds the one missing category, the ‘unknown knowns’  – the things we don’t know that we know.

CCGs are designed to combine two important elements of healthcare into a single, seamless function. Although their stakeholders are intended to be clinicians generally, their focus is on GPs, whose key purpose is to integrate healthcare delivery with referral decisions to ensure that the services in the specialist (hospital) sector effectively and efficiently fill any gaps in primary care provision.

For jobbing GPs, there will probably be little difference in their routines; they will still see patients, and refer those who cannot be adequately treated in the consulting room. In their referral decisions, they may be expected to conform to CCG rules as to where and when patients should be sent, but other than that, the transition to CCGs may – and it’s not such a bad thing – have little impact for the ‘grassroots’ GP.

It is at the organisational level that Rumsfeld’s aphorism may have more relevance, for CCGs will need to consider the strategic and operational aspects of commissioning, and indeed make sense of the term itself. Thus for example, at an operational level they will quickly need to understand the business models of their local trusts, link service availability with local population needs, identify and fill any gaps, and develop referral policies for which their member GPs will need to become accountable.

At a more strategic level, they will need to understand how the needs of their population may be compared and combined with those of neighbouring CCGs, grapple with medical and societal trends and juggle these issues with the political pressures that will constantly intrude.

They will also need to wrestle with the issues of probity that bedevil the whole of the British welfare state, but are probably worst in the NHS, where life and death issues overlay rational decision making, whether financial, legal, or clinical.

These are just a few examples of the tasks facing CCGs; the questions they raise concern the skills needed to succeed in them, how well equipped are they in these skills, and what help will they need to develop the ones they lack?

Which brings us back to Donald and his various permutations of known and unknown. There are skills in the CCGs that are so well established that their clinicians don’t even have to think about them: good general practices are so effective at understanding the interweaving complexity of patients’ physical and psychological problems and handling the uncertainties and probabilities underpinning good care care that they do these almost unconsciously. These are the skills that Rumsfeld missed out: the unknown knowns. We are so good at what we do that we forget how hard it is to do. Like experienced cyclists who give no thought to balancing their precarious machines whilst ducking and weaving through the traffic, good primary care clinicians are unconsciously competent at what they do. We should celebrate the dedication and training needed to achieve such effortless effectiveness.

However, there are many tasks for which CCG leaders will need new skills. They (generally..) realize that they need more financial and political skills to cope with their Local Area Team, the NHS Commissioning Board and the rules and regulations that could explode around them like land mines. These are ‘known unknowns’ where they are consciously incompetent, and where training is already under way. I have slight misgivings about the nature of such training, as the need to produce programmes ‘at scale’ for so many CCG leaders and senior staff feels at odds with the highly individual developmental needs of each person; it’s important to understand accounting systems, and the latest version of the NHS Operating Framework, but it needs a defter, more crafted approach to discuss how to cope with personal and organizational politics, or how to manage the care of too many people with too little money.

Finally, there are the ‘unknown unknowns,’ those problems that only become apparent when they become apparent. For instance, it’s likely that much work will be required to manage autonomous clinicians without losing their enthusiasm and dedication, or in re-invigorating the caring culture that has been so deficient in recent years, especially when the NHS (like every other vast bureaucracy) will continue to be reductive and punitive.

But even an external dispassionate view cannot predict unknown unknowns (or they’d be known unknowns…). The challenge is to have mechanisms in place in anticipation of the new, difficult issues, less to help in solving them than to support CCG leaders as they cope with their implications: for it is when blissful unconscious incompetence (‘commissioning is just an extension of what GPs do’) turns into conscious incompetence (‘OMG, what do we do now?’) that the risks are highest of the wheels coming off the wagon. And in this case, the wagon may be CCG leadership itself as much as the mechanics of CCG function.

Having high level, developmental support in place working with CCGs leaders will be crucial in allowing them to grow and mature in ability, confidence, and effectiveness.

You can take GPs to water, but can you make them drink?

This article was first published in Practical Commissioning on 12 December 2011, and shows the origins of some of the ideas cited in my blog about managing expectations (1 March 2013).

Image

What makes doctors choose general practice? When I made that choice, I was attracted by the idea of holistic whole person care, and of developing long term relationships with patients, their families and even their communities. There was also the appeal of ‘divergent thinking’, rather than the reductive mechanical approach that was followed in hospitals. But there was something stronger too, a pull towards the community as much as a push away from hospitals, something about self determination and control; doctors in general, and GPs in particular, are individualists who don’t think corporately. Is this down to nature or nurture?

As far as nature is concerned, medical schools select bright students with scientific backgrounds, and enough ‘open’ thinking to allow them to develop good clinical judgment. On the nurturing side, the emphasis throughout medical training and postgraduate development is on autonomy and the importance of personal accountability to back the primacy of the doctor/patient relationship, based as it is almost entirely on individuals.

We take this approach because society values the ‘sanctity’ of the consultation, and the fact that what happens between doctor and patient remains entirely between them. This mutual trust depends on this axis of confidentiality, and so anything that threatens the primacy of this relationship would be extremely hard to sell to GPs.

These thoughts came to mind when I was at the NHS Alliance conference recently, talking about the future of the NHS. I was thinking about what it takes to persuade the autonomous, self-determining, (generally) self-employed individuals who are GPs to change at all, never mind acting in a corporate fashion and taking on a externally imposed agenda, with a budget deficit and bureaucratic rules that would make even a seasoned civil servant blanche…

There isn’t a simple answer, but generally, if you want people to take on a new and risky role in a meaningful manner, you need to follow the dictum of ‘sell it, don’t tell it’. Those taking on the role need to believe in its value, see some benefit from doing it, and be exposed to as few surprises in its implementation as is possible.

Does this work if we consider the moves towards genuine clinical commissioning? Although the jury is still out about its effectiveness, most GPs like the notion of having more control over what happens to their patients in the secondary care arena. They are however highly suspicious and extremely cynical about the motives of the Government in setting out this agenda, many believing that any benefits will be in terms of money saved for the Government, rather than for improving services for patients or (dare one say it) benefitting GPs themselves.

Increasing the bureaucracy of the system (as already seems to be happening), making the approach ever more parental, and limiting the scope for innovation and diversity would all be excellent ways of smothering the changes before they even start; just look at what happened to practice-based commissioning, which ground to a halt even before it was fully established.

Moreover, in the words of the aphorism, ‘an expectation raised and dashed is worse than no expectation at all’, and over the past 20 years, GPs have had their expectations raised and dashed many times; whether we are talking about fundholding, ‘a primary care led NHS’, PCGs, PCTs, or PBC. In each instance, much effort was put into persuading the GP community that this was their breakthrough moment, only for each initiative to become diluted and eventually scrapped. For the evangelical GP, each step along this Via Dolorosa may be seen as inevitable on the path to salvation, but for the jobbing GP, perhaps vaguely interested but certainly not prepared to subsume her mortgage payments for the sake of eventual paradise, each dashed hope merely increases their sense of disengagement and cynicism.

If the current round of reforms isn’t fully implemented (and the current tussle between the centralising clusters and the nascent CCGs doesn’t look promising), Dr Average may well take his or her ball away for a very long time, and simply get on with the day job; and given that the day job includes indirect control of most of the resources of the NHS (wisely or otherwise), this scenario may be one that the Government wishes to avoid..