General Practice and the Transition from Clinical Commissioning to Accountable Care –2

Last time (here) I explored the negative impact that dual running the existing commissioning system and the future accountable care system was having both on general practice, and on the success of the new accountable care models themselves. We want GPs to focus on engaging with accountable care, to ensure general practice and the registered list is central to it. But the commissioning system hasn’t stopped, and we still want GPs leading and actively participating in the commissioning system.

By creating an artificial split between general practice as providers through federations and general practice as commissioners through CCG localities we are making it difficult for core general practice to be involved in the new models (How are practices represented? Do federations have a mandate to speak for practices? etc.), wasting valuable general practice time, and unnecessarily limiting the GP leadership capacity available to the new system.

If the heart of the transition is moving where the energy for redesign sits, how might we shift it from the GPs sitting in their commissioning role, to the GPs sitting in their provider role (rather than simply asking two different groups of GPs to do both)?

Could we transfer the responsibility for redesigning services from CCGs to groups of providers now? In practical terms, could we cope now without GPs carrying out their commissioning role, and ask them to take on the redesign role as providers, working with local partners? Could we transfer the resource we spend on our CCG locality structures to the GP federations (and what is the real return on the investment of that money anyway?), against a set of outcomes and outputs that we want in return? Wouldn’t that, in fact, be modelling the future?

Immediately I can feel the unease growing around the dreaded conflicts of interest. How can we give GPs the responsibility to design something they will potentially benefit from as providers? It has been the bane of CCGs in recent years, and this could feel like a step backwards.

But isn’t is true that within an accountable care model of providers working together within a fixed envelope of money, some of those providers sat round the table will end up providing more, and some will end providing less? The prevailing wisdom suggests the likely shift is from secondary care into primary care (a shift the purchaser/provider system singularly failed to enact). The logic of the new system is that, for the new system to be successful, exactly what we fear from a conflict of interest perspective (general practice designing services that shift resources into primary care) is what is needed for the new system to succeed.

If we place the redesign resource for a system into a provider partnership that the GP practices are part (maybe a major part) of, then all we are doing is modelling the future. We have to unlock the creativity of front line clinicians working together to improve the lives of the populations they serve. We can’t do that if we bind them in bureaucracy.

Attempts to develop a contractual approach to overcome the potential conflicts issue (the dreaded ACO contract) has already proven unwieldy and time consuming, focussing energy on form and governance structures and away from the key challenge of making change. In our transition plans from the old system to the new we need to find a way of shifting the energy for redesign as early as possible to make it central to the new way of working.

We are wasting valuable GP resource in dual running a system we are winding down alongside the new system we are trying to put in place. We need to accelerate the shift from the old to the new. The longer we wait, the harder it will be to engage general practice in the new model, and the more disenchanted they will be with the old model as it is dismantled around them. If we don’t do this now, then when?