The government’s plans for NHS reform place a great deal of power in the hands of the proposed NHS commissioning board, which will take on responsibility for commissioning primary medical care services as and when primary care trusts are abolished.

The recent consultation paper on commissioning indicates that the NHS commissioning board will be able to delegate this responsibility to GP commissioning consortia. The paper further suggests that consortia will have a role in “promoting quality improvement, reviewing and benchmarking practice performance and ensuring clinical governance requirements are met”. In effect, this means that consortia will have a dual responsibility of commissioning services on behalf of practices, and supporting them to improve their performance as providers.

At one level, this proposal recognises the impossibility of commissioning primary medical care services through the NHS commissioning board. Improving the performance of GPs as providers requires knowledge that can be derived only from detailed understanding of the work of practices and the populations they serve. Neither the commissioning board operating at a national level, nor regional offices acting on its behalf, could hope to acquire this understanding.

At another level, the proposal puts GPs leading the work of commissioning consortia in the position of challenging practices to raise their standards in a way that the best PCTs and practice-based commissioners have started to do. In the words of the consultation paper, this will entail “peer review and challenge in the first instance to areas where there appear to be unwarranted variations in practice or outcomes, for instance in relation to prescribing or the systems in place to support management of long-term conditions”. The hope is that pressure from respected and credible peers will be a more effective means of performance improvement than previous approaches.

But will it? It is often argued that doctors who choose a career in general practice often do so because of the autonomy of family doctors and their relative freedom from oversight and scrutiny. Much hinges on the willingness of GP leaders to take on the commissioning of primary medical care and their skills in engaging in difficult conversations with their peers.

Also important will be the incentives on offer to commissioning consortia. Practices will be required to be part of consortia, and a quality premium will be paid based on the outcomes that practices achieve collaboratively. With the success of consortia reliant on the performance of its members, this could create a powerful pressure for improvement if used skilfully.

This blog also appears on the King’s Fund’s website www.kingsfund.org.uk

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