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).


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..

Keep it simple, stupid – The KISS principle of managing conflicts of interest (first published 4 May 2012)

This article was first published in Practical Commissioning in May 2012

plumbing-basics-ga-1Over the years, I’ve been intrigued by the debates about conflicts of interests in the NHS. Are CCGs providers of services or genuine commissioners? Do GPs act in the interests of their patients, or do they more often line their own pockets? What are the most effective ways of ensuring that services are delivered effectively, efficiently, and within a national framework?

I have always been bemused by the issue, but perhaps I have an unusual view of the NHS, as I see primary care, incorporating GPs and CCGs, as the control centre from which all health services are co-ordinated, rather than simple service providers.

Let me illustrate this:

We recently had a new bathroom fitted at home; it’s very smart and it cost us a lot more than a ‘trip of a lifetime’ holiday. The work involved plumbers, electricians, carpenters, and tilers. I could have contracted with each of them separately, but not only would I have had to understand the details of each of their jobs and the limits of their capabilities, I would have had to carry all the ‘risks’; if anything went wrong, or more money was needed, the issue and the cost would have come back to me.

Instead, I went to a  bathroom centre, let’s call it ‘Baths 4-U’ and negotiated a deal; I don’t know whether the person with whom I spoke was a plumber, an electrician or even an accountant, but basically, I determined the ‘output specification’ of the bathroom, and left it to him to deliver the finished product. My obligation was to specify the functionality of the new bathroom, plus any specific details about which I felt strongly (please remember that the shower must accommodate my 6ft 9in height…), and between us we agreed the quality, the timescales, and the money.

This meant that I didn’t need to understand the technical details of the work, and that (within limits we agreed) it was up to ‘Baths-4-U ‘ to carry the ‘risks’. The plumber/electrician/accountant with whom I dealt then had to deliver the work; if he was indeed a plumber, he could do the plumbing himself, and sub-contract the other non-plumbing tasks to the appropriate technical specialists; if he was a generic accountant, he’d have to buy in all the technical services, and would probably be less successful than if he were a ‘content expert.’ As long as the finished product met the specifications of quality, timing and costs that we had agreed, then how he did it remained entirely up to him, and what profit he retained was none of my business. The key message is that Baths-4-U  were the body accountable for the work done

So how does this relate to the current NHS? Several parallels may be seen: at an individual’s level, patients are the ‘clients’ with a general sense of what their needs are, but without the technical knowledge or skills to manage them effectively. GPs are Baths-4-U, able and prepared to carry the risks (and reap the benefits) of providing a service; they provide most of the basic service themselves, and then sub-contract the more specialized technical services to the expert ‘tilers’ or ‘carpenters’ that are the hospital consultants.

Unlike home plumbing systems, health services also function at a larger, population based level, where decisions are required that affect whole organisations, rather than individuals. Although the principles remain the same, in this case the CCG is the accountable body, with the responsibility for organising and delivering all healthcare for their entire population, The ‘client’ is the NHS Commissioning Board, or any emerging local representative, that will need to define the outcomes being sought (quality, timing, price). As with ‘Baths-4-U’, how they do it should not be overly prescribed, or the creativity of the provider will be stifled while the ‘risk’ will be repatriated to the client, who does not have the appropriate technical knowledge.

In either case, if the accountability arrangements are clear, then there should be no conflicts of interests; quality, timing, and cost are the paramount measures, with the ‘client’ determining the ‘what’, and the provider having the freedom to decide ‘how’. At the ‘micro’ level of the individual GP, this is generally understood, but it is yet to be seen whether at the ‘macro’ level the central NHS ‘client’ will manage the three main tasks required to make the accountability work and to obviate the potential conflicts: can it resist over-defining the ‘what’? Can it bear to let the CCGs decide the ‘how’? And will it actually be able to hold the CCGs to account for those three outputs: quality, timing, and cost?