COMMISSIONING
which in time will illustrate whether medical care improves the patient’s physical and psychological functioning (7)
.
These well researched and discussed inefficiencies in health care delivery have failed to impact sufficiently on the delivery of health care to patients. One simple explanation of this is that efficient reform would redistribute the income and power of providers. Faced by such threats the providers have resisted change, thereby imposing waste and damage on taxpayers and patients.
Commissioners have been passive in the face of this provider power, relying on acquiring additional funding to improve services for patients rather than obliging hospitals and professionals to ease the constraints imposed by their restrictive practices.
How to improve performance?
The Labour government invested heavily in the NHS. Despite initial scepticism about the role of commissioning, Labour tried to improve the impact of the purchasers with initiatives such as “world class commissioning” but with little impact (1)
.
The coalition continues to emphasise commissioning and their “solution” is to give this role to GP consortia. This attempts to build on the experience of the 1990s when voluntary GP fund holding and “total purchasers” had some marginal observable effects in reducing the volume of elective care referred to hospitals.
Current plans replace the voluntary approach of the Thatcher-Major governments with compulsion and comprehensive responsibility for allocating £70 billion of the NHS budget. As these plans are
Nov/Dec 10
imposed, there will be focus on the size of the consortia, their management skills and the regulatory mechanisms put in place to protect taxpayers and patients.
The size of the GP consortia will matter because of the need to exploit economies of scale. The initial “hint” from Whitehall was that there would be 500 consortia but this was abandoned and not included either in the White Paper or the commissioning consultative document (8, 9)
.With
many GP poachers rapidly seeking to turn themselves into gatekeepers, the outcome of a preferred “evolutionary” approach is unclear.
With PCTs being abolished and staff costs being reduced by 45 per cent, unemployment is inevitable for many. The bright and the hopeful are rapidly moving to the emerging GP consortia. But will they have the right skills to manage providers efficiently or will they merely take PCT behaviours into the new organisations?
The BMA is advising its members to use public providers but when buying management expertise it is likely that consortia will contract with, or partner private insurers, both British and American.
This then raises nice issue about regulation. Will private providers be able to take over failing foundation trusts? Will failing GP consortia be taken over by private contractors? If the public-private mix is to alter who will appraise the efficiency of mergers which potentially reduce competition which is seen as the engine of improvement by the coalition?
The big question is how will health care delivery be integrated? No one in their right mind could defend health and
social care delivery being split into three parts, each of which seeks to defend its empire. Can GP consortia merge primary, secondary and social care to provide integrated care pathways efficiently? Or will this, as with PCTs, be beyond the power of GP consortia?
Some conclusions
The power of providers has ensured the continuing inefficiency of health care systems throughout the world. Furthermore this power has also ensured that commissioners, be they public bodies such as PCTs or private organisations such as insurers, have been unable to control provider driven expenditure inflation.
Continuous re-organisation of these commissioners has been to no avail. GP consortia may have beneficial effects but this is likely to be modest and uneven thereby further increasing clinical practice variations.
Any such progress has to be accompanied by supply side reform of providers. But this is where coalition policy is weak. A more even handed approach to the professions, especially to doctors, might usefully include rapid implementation, after 25 years of dithering, of efficient GMC reaccreditation procedures, compulsory inclusion in clinical audits using comparative activity, process and outcome data as a condition of employment for professions providing care to NHS patients and the alignment of financial and non financial incentives so that good practice and good outcomes are transparent and rewarded.
Reform of commissioning alone will not eradicate avoidable inefficiency and give improved expenditure control. Furthermore, delaying interventions to improve
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provider performance is a natural complement to improved commissioning which alone will fail.
GP commissioning is a fascinating experiment. Hopefully it will give, as evidenced by careful evaluation, benefits to patients and taxpayers. However, hope alone may not be sufficient. Without vigorous countervailing of provider power, the passive “bank clerk” attitudes of public and private commissioners may remain commonplace.
Professor Alan Maynard is professor of health economics at the University of York
References
1) Select Committee on Health, Commissioning, House of Commons, session 2009-10, HC 268
2) Cochrane, AL, Effectiveness and Efficiency: random reflections on health services, Nuffield Provincial Hospitals Trust, London 1973
3) Fisher, E, Medical care: is better? New England Journal of Medicine, 345,1665,2003
4) Department of Health, The Next Steps Review (Darzi report), London 2007
5) Department for Health and Social Security, Priorities in Health and personal social service, London 1976
6) Nightingale, F, Some Notes on Hospitals, 3rd edition, 1863.
7) Maynard, A and Bloor, K, Patient reported outcome measures (PROMs): walk don’t run, Journal of the Royal Society of Medicine, April 2010.
8) Department of Health, Equity and Excellence: liberating the NHS, Cmd 7881, July, 2010.
9) Department of Health, Commissioning, consultation paper, London July 2010.
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