By James Gubb director of the health unit at Civitas, an independent social policy think tank

2010

The NHS White Paper has garnered no end of controversy, not least its plans to transfer responsibility for commissioning health care from Primary Care Trusts to ‘consortia’ of GPs by 2013.  The aims are laudable: to push decision-making closer to patients and local communities; to ensure commissioning is underpinned by clinical insight; and to enable primary and secondary care to work more effectively together.  Many PCTs, as things stand, are not delivering.  However, there are valid reasons to question whether the restructuring is really a good idea.

First, while the evidence that exists on GP-led commissioning in the NHS shows there may well be some benefits – GP fundholding in the 1990s delivered improvements in speed, access and responsiveness of secondary care; reductions in waiting times; slight reductions in referral rates and costs;, and widening the range of available services – it is no certainty that these will be greater than what could have been delivered by PCTs.  Importantly for the current financial climate, GP fundholders, for example, failed to reduce costs as much as expected or improve patient experience.

The evidence that exists on GP-led commissioning also comes from a different context to that proposed: one where GPs could volunteer to take on hard commissioning budgets for a sub-set of care (GP fundholding and total purchasing pilots in the 1990s), very different to now where every general practice must be part of a consortia and hold budgets, and the risk, for the vast majority of health care.  In the United States, where the latter has been tried, only one in 10 associations succeeded both financially and in terms of improving patient care, according to the Nuffield Trust.

Second, while the White Paper places a keen emphasis on increasing choice for patients and stimulating competition between providers to drive standards, it is unclear that GPs will have the clout or skills to deliver this through effective commissioning.  As yet, the Coalition Government have not enunciated their vision for commissioning clearly enough.  The term still means different things to different people: 1) the management of existing contracts through defining cost and volume, 2) buying the services that will provide the best value (in terms of quality and cost) for the patient, 3) the management of clinical decision-making and how this commits resources.  GP consortia will be well-placed, and probably better placed than PCTs, to do the latter.  However, whether or not consortia can do the more fundamental second effectively is an open question.  This would require bringing in alternative providers (from the voluntary sector as much, if not more than, the private sector) as a competitive challenge to acute trusts to up their game, reconfiguring services, and shifting patterns of care.  With modest commissioning skills and (probably) smaller size in terms of population capture than existing PCTs, this may be beyond the majority.

Third, one cannot and should not ignore the possible impact of such fundamental restructuring of commissioning at a time when the NHS faces its greatest ever productivity challenge: around 4-5% per annum over this parliament according to the King’s Fund/Institute for Fiscal Studies.  Ironing out inefficiencies within organisations may well achieve this in the first one or two years, but, moving on from that, radically new models of care will be needed across the board – not least those that transverse the primary/secondary care ‘divide’.  This will require strong commissioning.  Yet it is highly questionable whether this can be achieved in an organisation naturally inclined towards the status quo, while attention is diverted to creating new structures and dismantling old ones.  It is certainly beyond what the NHS (-0.4% average productivity), and much of the private sector (+2.3%), has achieved in recent times.  In 2006, when 203 PCTs were merged, performance on finance and quality of care dropped the following year; it took on average three years for their performance to catch up with the relative performance of those that weren’t merged.

Fourth, the underlying assumption of the White Paper reforms is that, in acting as commissioners, the interests of GPs will necessarily align with the interests of patients.  This may or may not be the case: acting in the true spirit of the professional, they may well do, but it is easy to imagine a situation where GPs may be captured (consciously or unconsciously) by self- or provider-interest – as happened in PCTs with provider arms.  Why, for example, do GPs over-populate more affluent areas and under-populate poorer ones?  Why are there still such significant variations in clinical practice?

Related uncertainties include the following: what system of risk/reward will be implemented for GP consortia to 1) motivate involvement and 2) provide proper incentives for them to stay within budget and focus on improving outcomes for patients?  Will commissioning budgets be separate from practice budgets and, if they are, does this provide the necessary incentives to commission effectively?  How will consortia be able to influence primary care if contracts are to be held by the NHS Commissioning Board?  How much freedom will the commissioning board allow GP consortia, particularly given the risks in transition are significant?  What happens, also, if a consortium does not meet the perquisites to be authorised?

There may, in fact, be a better way: a way in which we might achieve the benefits of improved performance and increased localism and clinical input, without another round of top-down restructuring.  First, the shackles should be taken off PCTs.  They should be freed of interference from Strategic Health Authorities (which the White Paper is right to abolish); and assessed by the outcomes they achieve not the processes they follow. Second, to increase clinical input, GPs could be given increased statutory influence over PCTs and be able to take them over, following a rules-based procedure.  Third, there should be a rules-based failure regime: a 90-day notice period where other PCTs or entrepreneurial groups of GPs have the option of taking over a commissioning organisation that is failing.  Fourth, PCTs should be free to change organisational form and governance structures: to merge and de-merge and, more radically, form as mutuals or cooperatives.

The Coalition Government spends much time talking of the ‘Big Society’ and localism.  True localism would permit a series of locally-initiated experiments in commissioning that could be learnt from, rather than further centrally-initiated engineering that has failed the NHS throughout its history..

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