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GP commissioning: insights from medical groups in the United Statesmore energy should be spent on building future leadersand regarded the involvement of more women who oftenwanted to work part-time as a challenge that had not yetbeen fully addressed.Engagement of doctorsPhysician leaders invested considerable amounts of timein developing and maintaining relationships withrank-and-file doctors. There was a range of opportunitiesfor doctors to be involved in governance of the group,for example attendance at general membership meetings,or monthly board meetings, which offered a chance for alldoctors to catch up on organisational and policydevelopments.Work on committees likewise represented an importantroute for doctors to interact with the leadership and awider body of peers. All four medical groups had awide range of committees with different functions,including for setting quality standards, negotiating ratesof compensation for specialists, or reviewing referrals.Doctors were generally compensated for attendanceat committees.In addition, some groups had developed othermechanisms for involvement, for example assigningnew doctors a mentor for their first two years in thegroups, or offering educational opportunities such asshort courses, or a two-year mini-MBA programme.These covered a range of topics, including how to runmeetings, the intricacies of coding and contracting,negotiation skills, and more conventional clinicaleducation. Offering educational input was described asan important way of enabling doctors to understand thebusiness of the group and develop the organisationalculture. There was a strong sense that it was important toreach out to all doctors, even though this could bechallenging in practice, particularly for the IPAs, whichhave a looser, non-employed structure.“We struggle to get the attention ofdoctors who don’t come [to meetings] eventhough their local leaders come. We tryemails, we try meetings, no one singlething works.”Medical director, IPAOn the other hand, the message was clear that if a doctordid not fit into the ethos of the group, then the ultimatesanction was for them to be excluded.“We work with physicians and if they can’tget comfortable with our system and our wayof working, they move on.”Medical director, medical groupThe interviewees reported this to be a relatively uncommonevent. However, they described how they viewed theirorganisations as appealing to a particular kind of doctor:those wanting to avoid the administrative burden and longhours of solo practice, but nevertheless retain someautonomy. This was reflected in the comments of doctorsabout why they had chosen to join physician groups orIPAs, as outlined in Box 2.Box 2: Doctors’ perspectives on groupmembership“I have a young family and working here has given mepredictable hours and allowed flexibility over my lifethat wouldn’t otherwise be possible.”Employed group doctor“What attracted me here is that it was an organisedgroup, with a lot of organised processes of care inplace to manage care. Here, I can just be a physicianand not worry about running a day-to-day business.”Employed group doctor“It’s a nice way to practise because even though youare part of a big group, day-to-day it still feels like asmall office but you’ve got this big infrastructuresupporting you.”IPA doctor“I don’t have to worry about hiring and firing orany of the IT support, that’s all taken care of, but ofcourse we do get final say over hiring people to workin our office.”IPA doctorManagement of riskThere was significant variation in the scope of the servicesfor which groups took financial risk, in other words, in therange of services for which they held a commissioningbudget. There was no standard package of services acrossprimary and secondary care, and groups dropped andpicked up the budget for some services each year, based8www.nuffieldtrust.org.uk/publications