The traditional view of the NHS has been that control must be exercised from the top down or financial chaos will ensue. But this logic has been overturned by the coalition government: central control and scale are the problem, not the solution.
The economies of scale that look so attractive have never delivered. Look at NHS productivity during the last decade, a period of record investment during which the budget doubled and productivity steadily declined. It may be simplistic but it’s tempting to suggest that some things are too big to do nationally and need to be broken down into smaller chunks. In the new language, these chunks are GP commissioning consortia.
There is no question that GPs are the best people to be in charge of commissioning, so long as they work with acute trusts, local authorities, community services and other primary care clinicians to make commissioning work. The nagging doubts surface when the spotlight swings from clinical to financial matters.
On the face of it, the decision to abolish primary care trustss and replace them with several hundred commissioning organisations is illogical. This collection of small organisations is newly formed, still finding their feet, working out management problems, fighting turf wars and learning to be commissioners. How will they also manage two-thirds of the NHS budget when bigger, more experienced organisations failed even though they were staffed with full-time managers?
This question becomes even tougher to answer when you remember that at the same time as GP consortia are cutting their first teeth, they are also being asked to find £20bn in savings over four years.
The logic behind GP commissioning is that problems that were intractable at macro scale are addressable with microsystems. PCTs deal with large populations of anything up to 1 million. They deal with data that enables them to measure the performance of their services against national or regional standards but does not reveal an accurate local picture.
PCTs understand perfectly well that if you can move care out of expensive settings, usually hospitals, and into primary care and community settings, there are huge savings to be made. What they have never understood is how to do this fairly and safely. Why? Because PCT managers are too far removed from the problem to make sense of the data and because they lack the clinical expertise to make the right commissioning decisions.
A PCT discovers that it is spending worrying sums on hospital admissions of patients with chronic obstructive pulmonary disease (COPD). It considers the data that compares its spending to that of neighbouring PCTs and those with similar demographic profiles, which confirms that it is an outlier. It conceives a health strategy to keep that group of patients out of hospital.
In this case, the intervention would have tackled the wrong thing, the money would have been wasted and the cost of admissions would have stayed the same, because the spike on the COPD chart was caused by the way the hospital was managing and coding some patients.
Good PCTs with good working relationships with local clinicians have been able to get to the bottom of some of these issues. This year NHS Primary Care Commissioning released a tool that identified more than £5bn in savings in a range of areas, including referrals and prescribing, that could be achieved if the poorer performing PCTs attained the standards of their better performing colleagues. The tool can identify where particular PCTs have problems, but it’s then up to the PCT to validate the data with clinicians and to work with them on solving particular problems.
Most emergencies arrive at hospital in an ambulance. How many commissioners are working with ambulance trusts to dig down into the data to work out the relationship between cause and effect? Why are people calling an ambulance? What other services could, or should, they access? Why are they not aware of or using these services? How many of those journeys might safely be diverted from a hospital to a health centre, a walk-in centre, community hospital or a GP surgery?
On the answers to questions like these hinge hundreds of millions of pounds of savings, but the solutions cannot be found at the level of regions or PCTs. They depend on clinical knowledge. The numbers only tell part of the story, but it is GPs that know which patients and which clinical pathways are driving the data. Without this local knowledge, the data is useless.
Helen Northall is the national director of NHS Primary Care Commissioning
