Most agree that the main challenge facing the NHS is how to achieve an efficiency gain of 4% per annum between 2011 and 2015 without compromising the quality of care.
More effective commissioning is going to be crucial to this endeavour and clinicians undoubtedly have a major, beneficial role to play in improving how health services are planned.
However the government’s proposed changes will take place at a time of tremendous financial stress for the system. The Nuffield Trust has identified five key areas where work might help to improve the chances of the reforms meeting their objectives, with a minimum of disruption.
First, reinforcing this week’s recommendation by the Health Select Committee, we have suggested that the formation of PCT ‘clusters’ needs to be speeded up, with assurances given about their longer term existence so that they can attract and retain the best talent. If allowed to, such clusters could perform a valuable long term role helping to manage financial risk, providing commissioning support to consortia as well as overseeing the contracts for local primary care providers on behalf of the NHS Commissioning Board.
Second, shadow GP consortia should be required to meet an explicit threshold before proceeding to fully fledged consortia status. Evidence from the last 20 years of various forms of GP commissioning, and from international experience suggests it will take years for GP consortia to become effective and well functioning across a wide range of health services.
In the same way as the authorisation regime for Foundation Trusts, GP consortia could have a similar explicit authorisation regime that enables them to manage the commissioning of good quality care across a progressively wider range of services, and handle increasing amounts of NHS funds effectively.
Third, the decision to allow maximum prices to be set and negotiated in key areas (in particular for services for mentally ill people) must be reversed. International evidence shows that price competition in hospital care is associated with a reduction in quality of care.
Fourth, more transparency in the way that financial risk is managed and resources allocated is needed. In Liberating the NHS: Legislative framework and next steps, the government suggests that the NHS Commissioning Board ‘may establish a contingency fund to make payments to consortia to discharge commissioning functions. The NHS Commissioning Board will also have the power to adjust consortia allocations in future years to reflect previous underspends or overspends’.
The principles of allocation to the NHS are on the basis of health needs and there is potential for allocations outside this process to be ‘regressive’; in other words, not based on need. It is vital that the principles and rules for sharing financial risk are made completely transparent to consortia if they are to be confident that there is a fair and predictable process.
Finally, the evidence suggests that to be more effective than their practice-based commissioning and fund-holding forebears. GP commissioners will need to very work closely with their specialist colleagues in community, social care, mental health, and secondary care settings.
There have been some radical and promising developments across England along these lines already, although these may now be at risk because of the fast pace of organisational reform. Nevertheless they do hold up the promise of reducing unnecessary hospitalisation and better support for patients at home.
As this is where many of the greatest savings can be made, special provision should be made so that these undertakings can continue, and in time be evaluated. Ultimately, it is their experiences that may hold the keys to far greater efficiency and a better patient experience.
Judith Smith is head of policy at The Nuffield Trust
