Do GP Commissioners need MBAs?

by Rob Findlay

In his blog, Paul Corrigan repeats a familiar and widely-held view of the NHS commissioning reforms:

The Government plans to bet the whole of the NHS on the belief that GPs can deliver a business model that can buy £60 billion of NHS health… it is to be hoped that GPs understand how to operate in a business this size. …they will need skills that can work businesses with a turnover of £200-300 million pounds – hundreds of times bigger than the normal GP practice.

Dramatic. Astonishing. And thankfully, nonsense.

Firstly, GP’s already “understand how to operate in a business this size”, i.e. the size of the NHS, because that’s where they work now.

GPs also know how to “buy £60 billion of NHS health” (or at least their share of it) because every referral is a purchase, and that’s how much the referrals add up to. Each purchase is decided by the GP; and they always have been, which is why PCTs (and Health Authorities, and District Health Authorities, and Area Health Authorities before them) could never control their budgets.

So if the world is not going to change overnight for those GPs who aren’t actively involved in consortia, what about those who are? Will they be running giant corporations? Hardly. Here are some examples of real “businesses with a turnover of £200-300 million pounds”:

  • Bovis Homes (466 employees)
  • Majestic Wine (800 employees)
  • Photo-me International (1,485 employees)
  • Oxford Instruments (1,531 employees)

Even those GPs who are running Consortia will not need “skills that can work” businesses like these. They won’t be operating, managing, or even supervising this value of care. Instead they’ll be commissioning it. Quite different.

So what skills will commissioning require?

We could look for an answer by turning to present-day PCTs. There exists a long and dreary list of all the things that PCTs (supposedly) do at the moment. But do they really “undertake service redesign at a health economy level”, or “manage the local provider market”, or even “provide effective support for carers”? And even if they set their minds to it, could they? The reality is that, no, they couldn’t. Many fine words are written, but they are unmatched by deeds. Back in the real world, providers carry on doing their own thing; many carers remain ineffectively supported. GP Consortia do not need to take on the burden of pretending to deliver all that, and I’ve never met a GP who would want to anyway.

Nevertheless, commissioning something as complex as healthcare is a delicate business, requiring a high level of specialist expertise and commitment. The commissioner does not need the very high level of specialist expertise possessed by the provider, but a high level of general training and experience is certainly needed in order to place orders intelligently. The commissioner needs to be able to evaluate the needs of each case carefully, and commission a level of healthcare that is proportionate to that.

Strip all the fancy language away, and you can see that this is what GPs do all the time. They are general practitioners after all; not specialised, like consultants, but highly trained and experienced nevertheless. They use their skill and judgement to decide whether and how to refer each patient on to secondary care. That referral is equivalent to placing an order: commissioning, in NHS parlance. Which is what they do already: being GPs, not some multi-gazillion pound Master of the Universe type thing.

Neither is it a harmless pastime to exaggerate the challenge facing GP commissioners. Yes, they will be taking on more than they do now; they will have a budget to manage within, after all. But there is no need to make the challenge bigger than it really is or it might scare even the able ones off.

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