By Theo Cronin
Next time you go to the doctor’s, try asking how they are for once -the answer may surprise you.
“Morale amongst my colleagues is the lowest it’s been in all my time as a GP,” Dr Julius Parker told me, as we discussed the major reorganisation of the NHS that took effect last Friday.
Multi-million pound budgets are now the responsibility of a complex architecture of new commissioning bodies aimed at putting GPs in the driving seat.
But with the imposition of a new contract that makes them work harder, will they have the time or inclination to take the controls?
And with the defunct West Sussex Primary Care Trust replaced by a plethora of new bodies, does increased bureaucracy threaten to bind them with red tape?
Talking to local medical professionals in West Sussex there seems to be a widening gulf between the stated purpose of the Government’s NHS reforms and the emerging reality for doctors on the ground.
It was this chasm of cause and effect that I wished to explore with Dr Parker, the chief executive of the Sussex and Surrey Local Medical Committee, the professional representative body for all NHS general practitioners.
In principle, engaging clinicians with the commissioning of health services was to be commended he said, but he had a number of reservations concerning how this was supposed to be achieved.
His comments about morale came as we discussed the Government’s new contract for GPs, also imposed last week, following a breakdown of negotiations before Christmas.
“It is absolutely clear that the demands of the new contract increase workload for GPs,” he said, damaging morale at a sensitive time.
Doctors were already expressing a number of reservations concerning the reorganisation in which they are expected to play a greater role. Surely this was a barmy time to destabilise their morale further - is it a recipe for disaster I asked?
“I think it is very unwise for the Government to assume that GPs will continue to be able and want to be engaged in Clinical Commissioning Groups when the impact of the 2013/14 contract is going to be negative in terms of workload and their ability to provide patient care.”
Clinical Commissioning Groups, or CCGs as they are termed by clinicians swimming in a sea of new acronyms, replace much of the function of the dissolved Primary Care Trusts, or PCTs.
There are three CCGs in West Sussex, in which GPs and some consultants will be responsible for commissioning hundreds of millions of pounds worth of health services to meet patients’ requirements, including most hospital services.
But there are lots of exceptions, and many other bodies will now be involved in commissioning, where before there was just the Strategic Health Authority and PCT.
I asked Dr Parker to name the new organisations that have a role to play in the new commissioning process.
He drew a deep breath before listing Clinical Commissioning Groups (CCGs), the NHS Commissioning Board, Area Team for Sussex and Surrey, Health and Wellbeing Boards, Academic Networks, Clinical Senates, and Public Health England and the local authority which is now responsible for Public Health.
“It is really complicated,” said Dr Parker. “It is very disappointing that the initial idea has been dissipated by involving a multiplicity of different organisations.
“I think it is going to make it more difficult for CCGs to achieve their task because their energies are going to be more widely focused.”
Dr Parker also feared a repeat of lessons already learnt.
“Many CCGs are relatively small organisations compared with PCTs,” he said, continuing to cite how five PCTs in West Sussex were merged into one just a few years ago because they were deemed to be ‘too small to effectively exert their functions’.
“It would be very sad if we go through the whole cycle again and come to the conclusion that small CCGs are too small to affect influence over the commissioning process.”
Dr Parker said he was ‘deeply concerned’ about ‘experience and managerial capacity issues in smaller CCGs’. Reorganisations are also a frustration because they divert energy and time away from the real job of caring for patients he said.
Uncertainty reigns at times like these, the destabilising effect of reorganisation promoting a paralysis of decision making and management.
However, of greater significance is that the reorganisation does very little to solve the overriding financial difficulties affecting the NHS.
As the age of the population inexorably continues to rise, so does the burden of cost upon the NHS.
“There is an underlying driver that increases NHS care costs even if you don’t provide any more NHS care.”
I wondered if there had been a collective sigh from the GP community when the reality of the reorganisation had first dawned upon them.
“There is genuinely an enthusiasm amongst some GPs for the opportunities of CCGs,” said the GP representative.
“And CCG board members and those who are working on some of the CCG projects genuinely believe it is an opportunity for change.”
But he added: “I think it is fair to say though that this enthusiasm is tempered by doubt by a significant number of my colleagues.”
A significant proportion doubts the efficacy of the changes I questioned – would that be a majority?
“I would say that the majority of GPs are hopeful but remain to be convinced that CCGs will be successful in the tasks they have been asked to undertake.”
Dr Parker summarised his threefold reasoning again, with the doubt stemming from ongoing financial pressures not solved by the reorganisation, the size and limited managerial capacity and expertise of CCGs, and the ability of the system to continue to engage GPs when general practices’ workload is rising.
This latter point is compounded by the new GP contract imposed by the Government at the very time it is hoped doctors engage more with managing the system.
“I think the effect of the new contract will be to force GPs to prioritise their time, and CCGs may not be their first priority.”
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