In the sections above, we outlined variations in influence in a non-homogeneous professional group. Differentiating between formal and informal commissioning roles, the findings indicated that neither group had influence across both managerial and professional groups. GPs in formal roles acted primarily to overcome systems limitations, drawing on tacit knowledge to enhance commissioning decisions. However, their co-option into managerial roles undermined their influence among non-hybrid peers. For GPs engaging in informal roles, a lack of co-option restricted their ability to influence decision-making processes in the commissioning organisation. However, they were more able to act in a co-ordination capability to overcome socialisation capabilities by influencing their non-commissioning peers.
Exploring how hybrids mediated the limitations of their influence in different spheres, both formal and informal GPs indicated that they worked together to ensure that there was continued professional influence over managerial decisions. For example, an informal commissioning GP noted how a balance between formal and informal roles maintained a focus on the needs of patients:
There are a few clinicians who have devoted much more to this, but then they’re not doing very much clinical practice at all . . . but I think hopefully in our area we’ve actually quite a good balance between those who are dedicated to it full time and those who come in on a more limited, informal basis like myself. And we work together for the good of the patients.
CCG H, interview 8
Both groups of GPs discussed episodes during which they worked together to enhance or protect the status and influence of the profession as a collective. During interviews, both groups noted examples of when they had worked together, drawing on either the managerial influence of formal GPs or the professional influence of those in informal roles. For example, one formal commissioning GP highlighted
how they were able to use their understanding of managerial structures within the organisation to maximise the influence of the profession as a collective:
I know how the system works. I think I’ve used that to my benefit, to the benefit of colleagues and their patients by knowing who to go to when something doesn’t work . . . And so now the GPs might phone me and I know that if I make a couple of phone calls I can escalate that to the right contracts manager who can then put pressure on the provider to make those services easier [to access]. So there are lots of things like that where me having the commissioning knowledge and my colleagues in practice can come together to do good things.
CCG A, interview 4
Similarly, GPs engaging informally noted how they were able to act as mid-level brokers or mediators between the commissioners and their rank and file peers. In particular, one informal GP who enjoyed high levels of influence within their professional community, and who regularly engaged with the commissioning organisation, was able to communicate information and feedback across professional and managerial boundaries during a service dispute between GPs and the managerial staff at the organisation:
I knew the [commissioner] to talk to, so I had a word with them and made it clear what the GPs were concerned about, what they could do, and then I fed that back to my colleagues . . . at the moment I feel I’ve done my initial bit which is be the middle man and mediator with it . . . I’m not tied into the CCG, so I feel a bit more of a free agent to move between the two groups. I actively stay out of the formal commissioning part, and that means I’m not seen as such by my colleagues.
CCG D, interview 10
The GP in this case highlighted how they actively chose to remain in full-time practice, rather than taking on a formal hybrid role. In doing so, they were able to achieve influence by selectively engaging with managerial structures and commissioners without being co-opted.
Although the two groups of GPs used their professional or managerial influence in different ways, they were aware of the need to remain as two distinct groups, rather than diluting the formal or informal nature of their role to make the group more homogeneous. Both formal and informal roles were seen as fundamental to the ability of the profession as a collective to influence service change:
I take the view that my [GP] colleagues want to be left alone to get on and do their day job . . . I don’t expect all of them to be involved in service redesign because not everyone wants to do that . . . So I don’t expect them to be experts on that and how could they be? That’s a job that I take on to do for the CCG. And I’ll work closely with my peers who are influential in practice and that’s how we can achieve change.
CCG G, interview 10
At the same time, all of those who were interviewed suggested that their professional collegiality, and commitment to buffering professionalism from managerial influence, encouraged both groups of GPs to work together to retain professional control:
I feel that now, if we work together, we do have a genuine chance to possibly change the way the system works.
CCG A, interview 4 GENERAL PRACTITIONER INVOLVEMENT
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By working together in formal and informal roles, GPs could use their influence to achieve change within the commissioning organisation. For example, one informally engaged GP discussed a new service that had been designed and set up in collaboration with commissioning peers, and the resulting positive feedback from rank and file GPs:
Initially there was a lot of scepticism . . . But I worked very closely with [formal GP commissioner] and they pulled strings in the CCG . . . and I worked very closely with my colleagues in practice, so now I’ve had a lot of my colleagues say‘well, it actually sounds like you’re doing something rather than just sitting round a table and talking endlessly about things and not actually making any changes.’ So we’re now actually in the roll-out of that project and both the commissioners and the GPs are on board with it.
CCG K, interview 5
Ultimately, through collaboration, the two groups co-opted managerial processes, drawing on peer influence to encourage commissioning decisions that were aligned with the values of the collective profession, rather than driven by managerial demands. Although formal GPs actively took on commissioning roles, they combined their managerial knowledge of the commissioning organisation with the practical experience and influence of those in informal roles to enhance professional practices and protect professional jurisdiction. In doing so, they buffered the professional group from control by general commissioning managers. In conclusion, by working together, GPs in both formal and informal roles were able to co-optate managerial processes and maintain a form of professional resistance to managerial infringement.
Conclusions
General practitioner involvement acted as a co-ordination capability in two ways. First, by drawing on tacit or professional knowledge, GPs could enhance critical review capacity by overcoming systems limitations. Second, they engaged in clinical leadership to mediate socialisation limitations by using their professional background to influence peers in both primary and secondary care. This enhanced service design and delivery, and reduced the potential for professional resistance. There were variations in the way GPs engaged with the CCG, as some took on formal roles and others engaged more informally. Although formal GP commissioners had more influence over commissioning decisions, they may have limited capacity to overcome socialisation capabilities, because of their proximity to formal managerial roles. Those in informal roles had more influence over their peers, but faced inherent challenges as a result of the time limitations of their involvement and maintaining a clinical practice. However, we also noted how these two groups worked together to protect professional jurisdiction and ensure continued influence over commissioning decisions. We highlight the importance of this non-homogeneous professional group, and do not suggest that all GPs need to become formally engaged in CCGs, as their clinical practice is an important element of their professional influence. Commissioning organisations should be aware of the need to balance formal and informal engagement with GPs to maximise their potential as a co-ordination capability.
Chapter 6
Patient and public involvement
P
atient and public involvement is a legal requirement of UK commissioning groups. However, the extent to which PPI is used within the commissioning process is variable. All cases in our study noted that they acquired external information through standardised PPI mechanisms. However, the way in which PPI was subsequently used to enhance critical review capacity varied between CCGs. As noted previously inPatient and public involvement during the study, only three of our CCG cases asked us to focus specifically on the way in which they engaged with PPI during commissioning. These three cases illuminated different approaches to PPI, which were reflected across all 13 cases. We present the findings from the three cases to further illustrate the potential for PPI, and highlight how it is limited in CCGs.