Fishburn Hedges

22.07.2010

The publication of Andrew Lansley’s NHS white paper has sparked widespread (and heated) debate. By far the most controversial element of the proposals is the shift of commissioning power to GPs. 

Whatever the rights and wrongs of the expanded - and mandatory - role, for it to work effectively there will be some very practical challenges in communicating, engaging and equipping GPs to deliver the brave new world.

However you look at it, everything in the NHS white paper depends on GPs. In less than three years they will control 80% of NHS spending in England. 

They will take over responsibility for planning, commissioning and managing large parts of care on a local level. 

The scale and the speed of the change means the government has a major communication challenge. Unless it engages, motivates and prepares GPs effectively, its new world order for the NHS could stall before it starts. 

The government’s dilemma

Concentration of power at a local level is a major acceleration of the previous government’s direction of travel for the health service. Policies such as World Class Commissioning, and practice-based commissioning within it, were designed to facilitate design and delivery of care ‘from street level up’.

Whilst there are some strong advocates of greater GP control - who point to the effect that some existing GP commissioning groups have had on local health services – the approach also has its critics, who declare that many GPs don’t want or need extra responsibilities, or are simply ill-equipped to carry them out.

GPs are, after all, independent contractors to the NHS and the government has a mixed record of effectively engaging them with health policy. 

These polarised views have been evident in the fervent (and emotive) debate that has followed publication of the white paper. And they create a real problem for the government: it wants to move quickly into implementation mode, but it can’t do that without full buy-in from GPs. 

It has to change fundamentally the nature of the conversation it has with clinicians before it can proceed. 

The engagement challenge

The plans laid out in the white paper require a major cultural shift. GPs are a complex audience, with varying levels of understanding, ability and enthusiasm, but under the new plans each of them will have to play an active part in a new approach to health and social care.  

This can’t be change delivered through a ‘tick box’ approach. Nor can it be realised through a still-nebulous regulatory instrument (the NHS Commissioning Board). 

It will require a compelling and concerted engagement programme that informs, inspires and equips GPs across England. The way in which the government rises to this challenge will either underpin or undermine the effectiveness of its plans. 

The essential ingredients

This is a major challenge (particularly in an era of constrained resources) and there are some fundamental principles on which these communications should be based:

Show conviction - this is such a high-profile and emotive issue. Leaders in political and NHS spheres have to consistently spell out why they believe it is important to the future, and demonstrate complete commonality of purpose. They must paint a compelling picture of the difference this change will make to care. 

Make communication a conversation - no programme that seeks to change behaviour is based purely on the one-way flow of information. The government must openly engage with GPs and demonstrate that it is listening. It will need to develop a clear and simple framework to seek views and ideas and respond to feedback and concerns. 

Build the system around its people – if GPs are to take on responsibility for the health service at a local level, they have to feel and be treated as part of it, not as contractors or implementers of central policies. The key to achieving this will be extensive and sensitive engagement of representative bodies across the sector – the BMA in particular. 

Use the trusted voices - GPs trust other GPs: their views, experience and the lessons they can pass on. This peer-to-peer guidance must be at the heart of the conversation. As Mr Lansley has pointed out, ‘top-down’ communication (or instruction) doesn’t work. 

The role for government is not to tell clinicians how to do it, but to create a national framework within which sharing of knowledge, experience and innovation can thrive. 

Cast the net more widely - clearly, GPs are at the heart of the proposals set out in the white paper, but they are by no means the only clinicians with a strong understanding of patient needs, or a role to play in addressing them. 

The white paper has created a great deal of uncertainty among other clinical groups such as pharmacists. Their involvement in commissioning groups will be key to success, and government must not neglect to communicate with them directly, and their representative bodies, about the role they have to play.

As commentators have all been saying, Lansley’s vision for the health service is a radical one. It requires a great deal to be achieved in a very short period of time. But whilst there will be ongoing debate about structures and systems in the coming weeks and months, the imperative for proactive and concerted engagement must not be forgotten. 

Unless the government recognises and responds to this requirement, it will be very hard for the reality to live up to the vision.  

By Paul Sweetman and Ayesha Bharmal