Getting GPs involved in GP Commissioning

How will we get GPs involved in Commissioning?  GPs know the most about the needs of the patient (there are roughly 365million GP contacts with patients per year, compared with around 35million hospital contacts), and GPs have the most incentive to make the right decisions (GPs are stuck with the same patient for life, so the GP has to live with the decisions they make today).  GPs have a big incentive to be interested in commissioning, but GPs throughout the country aren't showing as much interest as you'd expect.

There could be all sorts of reasons for this.  I explore a few here:

What exactly is commissioning?

Commissioning is getting a reduced cost through the transfer of risk.

In the commercial world, you pay a premium for availability.  Let's two supermarkets at opposite ends of the spectrum for price - Lidl and Marks & Spencer (M&S).  Fresh fruit is similar quality in both of them.  But Lidl only gets a small amount in, and when it's gone, it's gone.  There's no waste, and no costs associated with waste.  M&S promises that there will always be fresh fruit (and just about everything else in its range), so naturally enough there's quite a bit of waste, and you pay for that.

A hospital is exactly the same.  Planned care can be scheduled and resources matched to demand.  But unplanned care (A&E) means having enough staff and equipment to cope with a sudden peak in demand, say a Road Traffic Accident.  And the price premium for A&E is about 50% more than the price of planned care, and if you actually look at the maths, unplanned care is actually subsidised by planned care because the actual cost of having these staff on standby is at least double per person receiving treatment.  No wonder lots of hospitals want to close their A&E, and private hospitals are so happy to accept tariff prices!

So if the GPs who refer patients are able to take the risk of planning the fluctuating demand and to manage it, they should expect to be able to negotiate better prices.

In essence, commissioning is about knowing your patients and getting your predictions right.

GP and Primary Care commitment to Quality

Getting predictions right is also about the overall quality of health care.  Inevitably resources are finite, so if I understand demand (ie the needs of the population), then I can make sure that the GPs I support will commission the right services to meet the needs of the population, and in the right quantities.  This will free up resources to do more for people who weren't getting care before, and also free up resources to innovate.


Innovation is expensive.  Setting up a new pathway takes managment and administration time and effort, whether that effort comes from doctors or administrators.  Setting up a new pathway also means that I need to have expensive people, hospital consultants and GPs, examining every stage of the process whilst we work out what works best.  So patients on a new pathway would go to a GP to be referred, and the GP would double and triple check the inclusion and exclusion criteria. Then the patient would see a hospital consultant, who again would check the pathway and whether the patient is in the right place, and also whether the pathway itself needs to change.  A 6 month or 12 month pilot could cost 5x more per patient than what the same pathway will cost when it is fully understood and provided by people following guidelines.  

A friend of mine used to say that at any one time, the NHS could save 70% of waste in the system by pathway re-design.  She didn't mean that the pathways were badly designed, she meant that our understanding of what works and how it works moves on so fast in health, that we could improve by that much in our regular cycle of re-design of any given pathway about every 7 or 8 years.

For example, diseases that used to require treatment in hospital with specialist equipment are now treated at home with hand-held testers and simple protocol-driven dosing.  Diabetes (Type 1) needs insulin injections to a particular dose - but the patient can treat themselves using a prick of blood for testing.  Heart disese can be treated with warfarin, again with a hand-held tester, following a protocol and look-up tables.  This change can only come about because people were willing to try something new, often expensively, to see how to improve.  And the vast resources freed up by these improvements can be used to tackle diseases which are currently incurable or which can only be treated in expensive hospitals, until they too become routine.

Primary care has an incentive to innovate.  GPs look after people from cradle to grave (actually from fertility advice and pre-natal to bereavement counselling for relatives), and live with the people who have the long-term conditions.  GPs do care, they just need to be engaged in the right way.

What do we do at The Social Return Company?

GPs are suspicious of administration.  Typically, GPs are people people, interested in caring for the person in front of them, and believe that only the highest quality will do and the cost doesn't come into it.

Our role is to help GPs understand what they can do by commissioning correctly, and by innovating - what they can achieve with the improvements and how they can provide better and better care for their registered patients.

A good example is work one of our consultants is doing as GP practice support officer in a Clinical Commissioning Group in the North East of England.  We spend time building a relationship with the GP practices, helping them to understand how commissioning works and showing them how to do things so they don't feel that it is a burden.

We show them how to use the tools of commissioning - understanding their own population and demand patterns, understanding innovation, putting forward bids to release funds for innovation.  We show them how predictive tools work, and run them on the GP practice' own patients so as to bring the results to life.  And we show them how to work with the other GP practices, not just at a personal level, but practically, sharing out the tasks and the duties so that everyone contributes, but everyone benefits from the work others have done.

It's a farsighted investment by the chair of the CCG, but it is paying dividends.  Perhaps it will help your GP engagement, and your budding CCGs?