In addition to GPs taking on a formal role within commissioning organisations, we identified a group that was actively engaged with commissioning organisations, but did not occupy a formal commissioning role. These GPs worked full time in practice, but frequently communicated information to the commissioning organisation through informal structures:
When I want to voice my opinion about something I usually go round [the formal GP commissioner] and just ring someone higher up, the chief operating officer or the head of urgent care commissioning or whoever it may be. They know me, I’m fairly well-known in the area, and I tell them what I think the issues are and what they should be doing.
CCG F, interview 14
In other words, there was another group of GPs attempting to establish themselves as professional leaders. They presented the front-line, real-time experience of the patient population to managers in the commissioning organisation, in order to influence commissioning decisions:
Rather than the very high level it’s actually‘What does this actually mean in practice?’and sort of brings a flavour of the situations that I encounter on a daily basis . . . that voice saying‘Actually is that really going to work? Is that really how it happens in GP practice?’.
CCG D, interview 3
General practitioners who were engaging informally with the CCG attempted to position themselves as professional leaders, suggesting that they had more influence within the profession than formal commissioning GPs, as those working in formalised roles no longer represented the reality of rank and file professionals:
All the clinical commissioning leads are really well embedded into their roles and sometimes you need somebody to be a critical friend saying‘Actually is that really what happens?’. . . You just need to be that person to say‘But is that really the right thing to be doing?’.
CCG D, interview 10
As such, informal GPs were better placed to overcome the challenges of socialisation capabilities faced by formal commissioning GPs, as outlined above. However, although those informally engaged aggrandised their position by highlighting their distance from the formal organisational management, their influence over managerial decision-making was subsequently reduced. As they did not occupy formal positions, they were unable to attend meetings in which strategic decisions were made, and their contribution was limited to the informal communications with commissioners outlined previously. Conversely, formal commissioning GPs were able to attend formal meetings as part of their role. Consequently, GPs who were engaged informally in commissioning reported less influence over managerial strategies than they might have liked:
I wouldn’t say I feel hugely influential . . . I speak to the commissioners fairly regularly, they ask my opinion and I don’t hesitate to ring them if I think they need to be approaching things differently. But I think the difficult part is not being able to attend meetings . . . I can’t be that person sitting there going‘What about this?’when decisions are made.
CCG G, interview 6
Although these GPs were able to communicate their ideas to the commissioning organisation, and were actively engaged in doing so, their influence over managerial decision-making was undermined by their lack of a formal role. However, despite their lack of influence within the commissioning organisation, informally engaged GPs suggested that they enjoyed having more influence among their professional peers. To this end, they positioned themselves as professional leaders among rank and file GPs, communicating the opinions of the professional community to commissioners. Further to this, as a result of their high levels of credibility because of their full-time practice-based roles, they were able to encourage and influence their peers to engage with commissioning decisions:
I think the fact that I’m a full-time clinician helps from a couple of aspects. I think it helps practices understand that there is value to these decisions, but also that clinicians just approach things in a slightly different way. I have more sway than the commissioners, my colleagues listen to me.
CCG A, interview 16 GENERAL PRACTITIONER INVOLVEMENT
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Their full-time position in practice, combined with their informal relationship with the commissioning organisation, afforded them more influence with their peers than formal commissioning GPs:
At the end of the day I’m going to be the one actually using these services every day, or being asked to do whatever they’ve decided. So I have influence in practice which is relevant, and I communicate back to the commissioners about how those things are working, or how they are viewed by other GPs.
CCG C, interview 2
Indeed, during interviews, in contrast to the self-aggrandising narrative of the formal commissioning GPs to communicate their professional influence, it was their rank and file peers who identified the practice-based GPs as leaders of the profession:
One of the partners here is very engaged with the CCG, he doesn’t work there but he’s always
e-mailing them, phoning them, pinning them down about things . . . I trust him more to tell them how it is, not to worry about whether it fits with their priorities. I’m sure the others [formal hybrids] do that as well at the beginning, but they must naturally get sucked into the CCG mindset.
CCG H, interview 8
The comments from rank and file GPs suggest that, rather than identifying themselves as professional leaders, those who engaged informally with the CCG were seen by their colleagues as professional leaders, and were more successful in overcoming limitations of socialisation capabilities. Although their lack of formal managerial involvement detracted from their ability to directly influence commissioning decisions, it facilitated their influence within their professional group.