Training and Perception – Commissioning fears.

Guest Blog by Dr Iseult Roche 

New GP trainees, at the beginning of their careers, are entering an area of health care which is at the heart of the most significant developments in the Health and Social Care Bill.

The promise for an efficient primary care led NHS seems a wonderful concept:

however, while  some eagerly await to see how these changes will materialise and  increase the opportunity for them to contribute further towards the health of their community – through efficient commissioning  as well as good clinical care – others are reconsidering their career plan to move away from General Practice.

There is uncertainty among some new trainees although it is hoped this will diminish when more detailed direction and structure is given by the Government to their plans. However, in the meantime two main concerns seem to be how training may be affected and what modification may be necessary, and, importantly, how the public will perceive GPs when they are in control of commissioning.

It is important to consider how the new commissioning role will influence future GP training. Concerns include: will GP training need to be extended to incorporate these new areas? Will trainees have to supplement their training with extra courses in their limited free-time? Will time be taken from clinical training to give to these areas? These are questions which those developing training are looking to successfully answer but no absolute plans have currently been given and only time will tell how they realistically work in practice.

Certainly commissioning and further management will have to be incorporated into course material. It is initially thought that commissioning training would be more relevant to qualified GP’s (those who have already reached equivalent ST4 for example, as you have to understand how to be a GP before you can take on Commissioning ).

However, early exposure to commissioning would be extremely useful, and ideally will be combined into initial training. For example, Kent Surrey and Sussex (KSS) Deanery is supporting, promoting and developing commissioning training  knowledge and skills and has appointed associate deans in commissioning especially to meet these needs successfully.

It is anticipated that commissioning may possibly be incorporated into the current Community orientation component of GP training, and it is expected that certificates in Commissioning will be introduced and integrated training pathways may be developed. Currently there is of course no statutory or mandatory training in commissioning amongst GP’s however, it will be necessary to encourage all practitioners to develop skill for their commissioning role.

Being a doctor requires life-long learning and no good doctor shies from this. Universities across the UK are currently preparing to meet new training needs. Post-graduate courses are being created and will develop and prepare doctors (both newly qualified and currently practising) for their new potential new role in commissioning and clinical leadership. These are anticipated to be in the form of Certificates and Masters Degree programmes. Loughbrough University and Warwick Medical School are running such courses and report that the number of enquiries has increased from both practising GP’s and those in training.

It does appear to suggest that doctors want to be prepared and to achieve a genuinely good position to meet their new responsibilities face on. They want to ensure that they are able to take on all commissioning aspects come April 2013, rather than run the risk that NHS Commissioning boards would manage that aspect until they are ready.

Further fear was originally generated amongst all doctors in training, by the initial plans to disperse Deaneries, and also the speed with which Health Education England (HEE) was planned to be introduced. The BMA has urged that deaneries be kept and, if no other option exists, placed under the auspices of Health Education England.

HEE is the autonomous statutory board, created to address national workforce issues which were not going to be provided by local providers including clinical commissioning groups, to hopefully improve financial and workforce planning. It is expected that HEE would also manage issues including commissioning education and training in specialist skills.

The speed of these new proposal was met with great resistance and the plans are now going to be reconsidered and further consultation will be taking place – which is a sensible move and demonstrates the Government wants to work with doctors to get plans right.

However, although plans are now that deaneries will be maintained within the NHS, to ensure any transition is smooth, the long-term future of deaneries is still uncertain. This is just fuelling fear in trainees across the board, who are concerned that their training could become a casualty of change without the infrastructure to successfully back it.

Even the most optimistic of trainees are concerned, with some seriously considering emigrating – which would be a loss to this country of tens of thousands of pounds in training. We can only wait for clear guidance and infrastructure to support these new changes.

Perception: The Four P’s of Preserving and Promoting Patient and Public trust are essential.  Doctors who choose General Practice purposely want to work in an area of Medicine that balances good clinical care with a unique position in their community. The patient-doctor relationship is intrinsically linked with trust, and this is especially so for GP’s.

New trainees fear that if GP commissioning causes perceived conflicts of interest, this unique relationship will be undermined, which could also undermine local health care provision and erode the basis of patient centred care. It is essential that the Government allays fears by introducing infrastructure to safeguards this – so patients and the public feel safe and confident this potential problem has been addressed adequately. Only then will the patient-doctor relationship be protected. However, currently, how this will be achieved is still unclear and it is this lack of absolute direction regarding potential conflicts of interest which is still causing concern.

The Government’s willingness to revise their initial plans of introducing the Quality Premium, whereby Clinical Commissioning Groups (CCGs) would receive payments from the NHS commissioning board based upon efficiency, will help to reduce one aspect of perceived conflict of interest, and shows this is on their minds. However, whether this will be enough to alleviate concerns, will only be known when the exact details of this revision are finalised and filter to the public.

The BMA has urged that it will be essential to ensure Quality Premiums do not damage the patient doctor- relationship by keeping this incentive separate from GP practice income.

It is also necessary that safeguards are balanced between providing public peace of mind without undermining the new role of GP’s in commissioning. For example the proposed plan that the NHS commissioning board should be able to abolish individual CCG’s if it deems necessary, without consultation, may well make the public feel there is an absolute safety net to close down a CCG which is not performing appropriately or where definite conflicts of interest have occurred. However, this will have to be balanced against the concern of GP’s who may feel this is a potentially heavy handed approach; even if there is clear structure to ensure these powers would only be used in exceptional situations. If any such abolition of a CCG was challenged by a request for a Judicial Review, it would be an unfortunate occurrence indeed.

NHS reform is an emotional topic, and yet progress is essential. The willingness of the Government to actively listen to doctors has been only right and also shows they are confident in their plans while still being able to modify them. Only time will tell how plans and concerns will progress – let’s hope this is as smooth a transition as possible.

(With thanks to Dr. H Whittaker- (KSS Deanery), and Staff at Loughborough University and Warwick Medical School)