Health secretary Andrew Lansley’s white paper offers a radical approach to commissioning care. Budgets totalling £80bn will be passed from health service managers in strategic health authorities and primary care trusts to general practitioners.
On the face of it, this has merit in that it should save large amounts of money on managerial staff and, at the same time, give doctors greater control of the NHS purse strings.
However, such proposals are not really new and they have been tried several times before albeit on a smaller scale than now proposed. In the early 1990s, the then Conservative government introduced the idea of GP fundholders in charge of commissioning budgets, while the successor New Labour government launched its own policy of practice-based commissioning. The present government will no doubt claim that what they are proposing is different from what has gone before, and in terms of detail it will be. However, the broader philosophy of enabling GPs to make decisions about the use of NHS funds remains the same.
Almost by definition, the proposed changes do give GPs the opportunity to exert much more influence on the commissioning of health services for patients. Unfortunately, experience from the previous approaches suggests a number of difficulties:
- GP commitment – for the new system to be effective, GPs must make informed decisions that could mean making changes in the pattern of commissioning between NHS trusts. To do this requires an awareness of the merits of the different services in different trusts and, unfortunately, while some GPs will do this enthusiastically others won’t. Examples can be quoted of GPs referring patients to consultants who had retired from practice. Thus, for the new system to be successful it requires a GP commitment that may not always be there.
- Inequity – while many GPs will use the commissioning freedoms to benefit their patients, others will be less enthusiastic and consequently the care offered to their patients might not improve at all. Many will argue that this is unfair and the quality of hospital care received by a patient should not depend on whether their GPs have done the appropriate homework. Some will argue that patients should press their GPs to use the new freedoms for their benefit but that is easier said than done.
- Accountability – while many GPs will welcome having the power to make commissioning decisions, they must also recognise that hand in hand with this responsibility comes the accountability for the use of public funds. This may involve various tasks of submitting financial returns and answering audit queries.
- Administrative burden – some years ago, a survey of GPs found that many of already felt over-burdened by ‘administrative tasks’ at the expense of face-to-face patient contact. Included in what they termed ‘administrative tasks’ were those of administering individual patient referrals to hospital. Involvement in the new commissioning system is likely to make this worse not better.
- Demand management – one of the key themes in NHS management is that of demand management, which concerns controlling the flow of patients to hospitals such that NHS commissioning budgets are not exceeded. This process was undertaken by PCTs but, presumably, will now fall to GPs themselves. No doubt the Department of Health and HM Treasury will need to be assured that effective financial controls are in operation to avoid major overspends.
- Strategic change – with the current commissioning system, the key role of GPs has (understandably) been to meet the need of their existing patients. However, PCTs have had a longer-term commissioning consideration namely that of reshaping local health services to meet the needs of future patients. This longer-term role is vital and must, somehow, be incorporated into the new commissioning system.
The new system will operate by GP practices working not individually but in groups or consortia to commissioning services. No doubt they will want some level of administrative support to make the system work and the trick is to ensure that these administrative costs are lower than what was being incurred by PCTs.
GPs wanted more power over commissioning and under the new arrangements they will have it. However, they have a conundrum. For the new system to be meaningful it is imperative that GPs get fully engaged in how the commissioning decisions are made and this will inevitably encroach on their patient contact time. On the other hand, if they only get lightly engaged and leave the detail to the managerial support staff then it would seem that little of substance will have changed and the managerial staff will still be the main influence on commissioning decisions.
Past experience suggests there are huge risks for the government in going down this road. In particular, there is a major concern about keeping control of NHS expenditure under such a system. So what might the government do if things go wrong and NHS expenditure starts to go out of control or patterns of commissioning lead to major financial problems in NHS trusts?
An option would be to revert to something similar to the current model with lower GP involvement and stronger managerial control. This might be difficult to achieve and a major political U-turn.
The alternative might be to get the private sector involved to take over some of the commissioning roles in a manner similar to the Health Maintenance Organisations (HMO) in the US. Several firms are already active in the UK in an advisory capacity and would welcome the opportunity to get more involved in operational commissioning.
If such a move took place, this might be a first step towards introducing a health insurance model for funding the NHS in place of the current tax-funded model. Fanciful – maybe, but something has to be done about the financing of the NHS.
Malcolm Prowle is Professor of Business Performance at Nottingham Business School and a visiting professor at the Open University Business School. He can be contacted via his web page www.malcolmprowle.com
