UK 'should learn from US GP commissioning failures'
Richard Johnstone | 13 June 2011
A US health expert has warned that the government’s
health reforms could lead to a loss of financial control in the NHS.
One of the main changes involves transferring
responsibility for commissioning of health care from primary care trusts to
consortiums of GPs, along with the £60bn budget.
However, Dr Lawrence Casalino, an expert on a similar
US health care policy, warned that only around a tenth of such consortiums were
successful in the states.
Casalino, a professor of public health at Weill
Cornell Medical College in New York, said that the US experience is that there
are ‘a great many ways to get the new system wrong and very
few ways to get it right’.
He analysed the more than
1,500 doctor-led groups set up in the US, called independent practitioner
associations. In a paper produced for the Nuffield Trust, he says only 150 were
successful at managing the risks involved in commissioning on a fixed budget
agreed with insurance companies.
US model failed and, after 15 years, the groups were trimmed back even in the
states in which it had been most successful, he said. Many
foundered due to a lack of strong clinical leadership and ‘underinvestment in
the management and infrastructure necessary to handle financial risk’.
While he believes the UK consortiums have the
potential to improve quality, he says they need support mechanisms for
accountability, including the ability
to make sophisticated financial projections and undertake complex financial
Casalino argues that the GP consortiums should be
encouraged to invest in leadership and management, as left to themselves they
are likely to under invest in these capabilities, increasing the chance of
failure. He suggests ring-fencing budgets for this purpose.
Among the other recommendations in his paper, Viewpoint: GP commissioning in the NHS in
England: ten suggestions from the US, Casalino says the system also needs
hospitals and specialist physicians to co-operatewith the
consortiums. Increasing integration and co-operation in the health system was
one of the changes announced to the plans by Prime Minister David Cameron last week, at the
end of the government’s consultation on the Health & Social Care Bill.
Casalino recommends that consortiums be given ‘space
to develop over time’, as they will need five to ten years to realise their
However, they must also be aware of the consequences
of poor performance, including financial consequences for individual GPs in
consortiums that persistently fail to meet financial and quality standards.
Casalino says: ‘Some GP leaders are enthusiastic about
GP commissioning, and their enthusiasm should be encouraged. But there will be
a great many ways to get the new system wrong and very few ways to get it
right, with significant consequences if failure were to occur.
‘The NHS has a significant advantage over the US
system in that it has the authority to restructure the entire system wholesale
and enforce common standards where appropriate.
‘To make the most of this, the system needs to find
ways to give consortiums reasonable amounts of time to develop without
subsidising to an unreasonable degree those consortiums that fail to improve.’