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Health reform signals a new world of GP influence, says primary care leader

4 October 2010

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MiP Editor

Dr David Colin-Thomé (pictured) retired as a GP in 2007, after 36 years as a family doctor in Runcorn, Cheshire. So when he spoke at September’s Management in Practice Event in London, it was with a sense of personal regret: he is, after all, missing out on a pretty exciting time. “General practice is going to have more influence on the health service than I could ever have dreamed of. So for 
me it’s a pity. For others, it might be a bit scary. But it’s a great opportunity.”

He’s not missing out completely, of course: just the chance to drive radical changes from the frontline. Indeed, as the Department of Health’s (DH) National Director of Primary Care since 2007, and the National Clinical Director since 2001, Dr Colin-Thomé is playing a key role in developing the coalition government’s health policies, sketched out in July’s health white paper. (Previously, he also led on the Primary and Community Care Strategy for Lord Darzi’s NHS Stage Review, published in 2008, and was the clinical lead for delivery of the 18-week referral programme.)

Moreover, one could argue that he has already seen his fair share of frontline action. Before the DH desk-job, his own GP practice in Runcorn, a pioneer “total purchasing site”, led the way in the systematic management of long-term conditions and in the space of three years realised more than £2.5m of potential savings on hospital expenditure.

This achievement would seem to make him the ideal GP figurehead at a time of deficit reduction and health service spending cuts. He is resolute about the importance of general practice to the wider health service and its strong foundation for the commissioning requirements that lie ahead. “The bedrock of the future, as in the past, is the practice,” he told practice managers at MiP London. “You can’t be a good commissioner without good providers, and so your job in the practice is the fundamental building block of everything we do in the future.”

Changing roles?
The white paper will not radically affect the day-to-day work of practice managers (his key message is “be not afeared”). “There will have to be good-quality general practice as we currently know it, only getting better: improving standards, broadening the scope of what we do – which is very much the stuff of good practice managers,” he told Management in Practice.

Might there be a role for experienced practice managers in GP commissioning consortia? “Consortia are going to have to have professional contract managers, some of whom might come from primary care trusts (PCTs), some might come from hospitals and some might be practice managers,” he said. “But if they want those jobs they’re going to have to apply for them and be trained up to do them because many practice managers won’t currently have those skills.”

What of GPs unwilling to engage in consortia? It has been argued that as many as 40% of GPs do not want the hassle of strategic planning – they just want to care for patients. Is there a risk of splitting the profession?

Dr Colin-Thomé rebuffs this outright. “What better than to be a good GP to your patients? That’s what the health service needs. Some GPs will want to be leaders of consortia as well as being GPs, some GPs will be looking to become chief executives of consortia, maybe even give up general practice. But if they want to be good GPs in their practice, that’s as important as anything. Good, effective general practice makes commissioning easier in terms of reshaping hospital care. It’s just different opportunities for GPs in the future.”

New faces at the frontline?
Then there is the accusation – as articulated by the British Medical Association’s Dr Richard Vautrey at MiP London – that the white paper has set GPs up to be the “fall guys” of the health service and that the government has somehow “devolved the blame” for spending cuts. “That’s a really negative interpretation,” said Dr Colin-Thomé. “If you look at how much money is spent on the health service, most of that money is spent by clinicians – eg, for referrals. So one of the ways to make more efficient use of resources is to have clinicians sorting that out.

“The negative ‘fall guy’ concept implies a doctor would rather be a bystander and complain about other people doing it than being active themselves. Well, some of us think that with our clinical knowledge we can lessen the need for inappropriate cuts and begin to challenge when money is being wasted. That’s why people like me are huge supporters of commissioning, because we wanted to take that responsibility and have the chance to do it more effectively than a management organisation.”

White paper sceptics have also pointed to the increased opportunity for private organisations to step in as commissioners of health services in cases where GP consortia lack sufficient resources. Does Dr Colin-Thomé think that we will now see a greater role for the private sector? “Only if consortia want it,” he said. “If the consortia don’t have the skills, and they can’t find the skills in the health service, of course they’ll have to get it from somewhere. So in that respect there might be – the answer is: ‘we don’t know’. But I have no problems with that if they’ve got the right skills.”

He added: “One of the issues for us is to begin to say, ‘How can we within the health service begin to set up support organisations for consortia?’ So a group of GPs working with managers and others might say: ‘We could be a much more cost-effective alternative to some of the more high-cost private sector.’ But consortia will need expertise, which won’t always be local, and they have to bring it in from somewhere.”

Regardless of who commissions services, he said, ultimately “who delivers the care should be the best person who can deliver care. And whether that’s private or public I’m quite relaxed as long as the NHS is a public sector organisation.”

Whether or not the private sector moves in, the white paper will lead to greater competition, at least among GP practices themselves, for another change it puts forward is the abolition of practice boundaries by 2012. As it also states that funding will “follow the patient”, will practices be protected if patients up sticks?

Dr Colin-Thomé expresses little sympathy for practices that might fail. “It’s for practices that lose patients to look at how they deliver care, because there must be a reason that patients are leaving the practice. Unless they’re moving address, patients have huge loyalties to their practices and their GPs. So if a practice was losing lots of patients, they need to look to themselves rather than say it’s a bad thing for patients to have choice.”

More empowered, but also more accountable: perhaps this will be the future of general practice. Many will relish having their GPs in the driving seat of the health service; perhaps others will retain a sense of disquiet until further detail is released. In any case, as Dr Colin-Thomé told delegates at MiP London: “I think our time has come.”