GP Commissioning will be good for patients and the NHS
Henry Featherstone 5:58pm
Quite why people are surprised that Andrew Lansley has stuck to his plans to introduce
GP Commissioning is a mystery. I’m struggling to recall one of his speeches or policy documents in recent years where it wasn’t mentioned. Anyway, let’s be clear, widespread
control of commissioning budgets by GPs was where the NHS was headed until Frank Dobson took over in 1997 and unravelled a decade’s worth of market based reforms. Rebuilding that
position has taken another decade of circular re-organisations to fix. No wonder the NHS is ambivalent about reorganisation.
These proposals are, of course, radical. But they are needed to address the fundamental flaws in the NHS commissioning landscape. The current system of commissioning – or buying
healthcare services - is considered weak by the Department of Health. Currently, GPs aren’t engaged in the process and Practice Based Commissioning (GP Commissioning without real budgets or
responsibility) hasn’t used scarce NHS resources efficiently. Only 30 percent of GPs think it has actually improved patient care. Of course, the NHS has improved in the last decade, but any
fool can spend more money; the trick is to convert it into improved health.
So will GP commissioning help? Well, it did before. Between 1991 and 1997 under previous fundholding arrangements GPs became better at allocating scarce NHS resources; they responded to
incentives and referral rates amongst fundholding practices fell. For example, admissions for elective procedures amongst fundholding practices were 3.3 percent lower than they would have
otherwise had been. GP fundholders also began to move services from hospitals into cheaper and more convenient primary care settings by attracting hospital consultants to provide clinics in
settings convenient for patients, not hospitals. In a competitive model where patients can choose which GP practice to go to, all the evidence tells us that these more efficient, patient
focused GP practices will prosper.
Moreover, giving commissioning and financial responsibility to GPs will actually help improve hospital efficiency. During the internal market of the 1990’s, fundholding saw hospital
efficiency increase by an average of 1.7 percent per year; but, after it was abolished in 1997 efficiency fell by an average of 1.6 percent per year. Overall, NHS productivity has fallen by an
average of 0.4 percent per year in the last decade and so any means of achieving a turnaround should be welcomed.
If anyone were to question these proposals, they might more helpfully direct their interest in implementation. On the whole compelling individuals to do something, especially educated
professionals, is not the best way to achieve high levels of acceptance and buy-in. However, it has to be noted that the move from GP fundholding to Primary Care Groups (the forerunners of
Primary Care Trusts) in 1999 was mandatory and that change passed without issue.
A different approach for implementing GP Commissioners might be to make an aspiration for high-performing GP practices, much like the introduction of NHS Foundation Trusts - which have been a
success story on any measure. Alternatively, a system of incentives for large GP practices or independent primary care providers could be introduced in areas where take up of GP Commissioning is
low, in the same way that Independent Sector Treatment Centers exerted competitive pressures on sluggish hospitals.
There are concerns too that in the long-run GP Commissioners will slowly merge into 300 or so larger consortia and that this will leave the NHS in a similar structural position as now, except with
300 GP Commissioning consortia in place of 152 PCTs. They are right, to some extent, but they miss the point. Structures are irrelevant, accountability is everything. Patients and
clinicians will be in control from here on in and that is the way to drive real healthcare reform.
Henry Featherstone is Head of Health & Social Care at Policy Exchange and author of Which Doctor?
Putting Patients In Control Of Primary Care.
Previous
davidk
July 13th, 2010 6:11pm Report this comment"I’m struggling to recall one of his speeches or policy documents in recent years where it wasn’t mentioned."
I'm struggling to recall one when he said the PCT's would be scrapped. Perhaps it's this type of stealth that fuels suspicion about the error prone Lansley?
mick
July 13th, 2010 6:22pm Report this commentWHAT HAPPENS WHEN YOU CANNOT GET A DOCTORS APPOINTMENT WHEN THEY ARE AT MEETINGS ORGANISING THEIR BUDGET OR RUN OUT OF MONEY BEFORE THE END OF THEIR FINANCIAL YEAR
Rabyrover
July 13th, 2010 7:25pm Report this commentMick
You can't get an appointment now.
Grah
July 13th, 2010 10:35pm Report this commentYou can't get an appointment now (at your convenience for every trivial request) as GPs have been dumped with a wide variety of (previously) hospital work, eg. follow ups and increasingly basic stuff such as issuing prescriptions and sicks notes that should have been done elsewhere.
Hospitals operate in a heavily unionised and nationalized fashion, with all the inefficiencies
that entails. Think British Leyland - and general
practice is the small independent producer like Norton bikes or TVR. PCTs have not levered up the nationalised inefficiencies, so it's time for a different approach.
Snowman
July 13th, 2010 11:53pm Report this commentOh, Henry, Henry, this is just tinkering, massive, costly and time consuming, but tinkering nevertheless.
The model of ‘free at the point of delivery’ cannot work, it won’t work whichever way you cut it. Just think for abit, it’s a system that’s open ended in regards the demand for its output, but limited at the input end. The country cannot afford the luxury of spending increasingly more and more. Other things like road and school buildings, fighting in distant countries and stuff have to be paid for, too.
By divorcing what one gets from the NHS from what one is asked to contribute to it, the model amounts to nothing but a big delusion totally on par with the Marxist inspired nightmare that has imploded so spectacularly in the East only two decades ago.
Will J
July 13th, 2010 11:53pm Report this commentThere seems to be some misunderstanding of the new plans, largely due to the way GP fund-holding was done previously. In the proposed model it is the consortia not the practices which are the fundholders. A consortium is like a PCT except that it is smaller and, crucially (as Henry says), its members are all GPs who have chosen to be part of it (rather than a different one). As such, the GPs will not each manage their own budget, but their consortium will manage their combined budget, and they will oversee its management as its governors. Therefore concerns about GPs having to be managers and it taking up lots of their time are misplaced.
At least, that is my understanding of the model having read the paper.
Anan
July 14th, 2010 12:56am Report this commentIt's about time those lazy GPs actually did some work. It will be good that they have to manage the budgets now.
charles hercock
July 14th, 2010 8:35am Report this commentRabyrover and Grah-you know that is not true-the 48 hour target gives a lie to your nihilism
PayDirt
July 14th, 2010 8:45am Report this commentHenry: This is so much ideological claptrap. It will not be good for patients at all. It will be good for GP’s. What the NHS needs is not a retrograde step to the bad old days of having to beg your Dr for treatment, what it needs is an army of debt-collectors. All those people who take advantage of the NHS without contributing, they need to be made to pay up or get out. So simple but ideologues like you lefty “conservatives” can’t see it. I despair at this stupid stupid backward step, and to think what the bastard Socialists will make of it in due course. A complete wasted opportunity. Bah!
David Bouvier
July 14th, 2010 10:13am Report this commentPaydirt - do you actually have any estimates the amount of money spent on non-emergency care for people not eligible for free care (noting the EHIC arrangements and others)? Or is this a some kind of anti-foreigner venting...
Now you are correct that NHS hospital staff essentially refuse to validate the eligability of even the most obvious cases, which is an issue, but it is a just a pimple of face of NHS funding.
PayDirt
July 14th, 2010 10:45am Report this commentDavid B: No I have no figures, I guess you don’t either as you use the word pimple instead of x% of £Xbillion. No, I want to be positive about the NHS. It could be the flagship prize of the Nation. A system of delivering medical care which is second to none. It could even be a revenue source if the UK would actually charge people the going rate. But it is only an Idea, free medicine for all. The figures I want to know are basic: how much does the Govt receive in NI contributions? I know the outgoings in pensions is an unfunded nightmare, however there should at least be a figure of how much current pensions cost, and how much the NHS costs. This is the sort of “accountability” I want to feel more at ease with. The problem I fear is the NI contributions are not linked to the service the NHS provides for its customers. I pay my dentist £x00 a throw, I get to switch dentists if I’m unhappy. GP’s however I’m stuck with. They send me on wasted trips to the clinic because they don’t read the case notes properly, they have not the time to do a better job. I see the dentist for 15 minutes and we communicate. I go see the GP and it’s a long wait then a rushed 5 minutes and out the door clutching a piece of paper the Pharmacy has difficulty in deciphering and not signed anyway. Not the envy of the world is it?
TomTom
July 14th, 2010 2:06pm Report this commentGPs are history just like mutual building societies. Already there are Salaried GP Contracts and Contractor GP Contracts and the public is clueless.
The majority of new GPs are female and part time.
The future lies with Polyclinics employing part-time doctors on rota and medical records held by NHS Inc the Insurance Fund with Database.
Patients will drive to Polyclinics in major cities to see whatever doctor is available - the fictional GP who had a patient list is already history as the Patient is registered with the PCT not the GP
David Lindsay
July 14th, 2010 4:21pm Report this commentI have always rather liked Andrew Lansley.
But he is hot on the heels of Michael Gove's "If your local school is too prolie or darkie, then we'll cut the building of and repairs to schools for proles and darkies so that you can set up your own school, even though you could perfectly well afford to go private".
Lansley's variation is "You can have any treatment you like - heard on the radio, seen on the telly, read on the Internet, anything - and the taxpayer will pick up the tab, whether or not your doctor thinks that you, or anyone, should have it".
Gove's and Lansley's party has very limited contact with the public services, and it simply does not begin to understand them. Therefore, it ought not to be put in charge of them.
Rickyroo
July 16th, 2010 8:24pm Report this commentWhy have all commentators failed to mention that Andrew Lansley accepted a donation of £21,000 for his camaign from the head of a private health company so of course he wants to try and privatise the NHS
BB
September 29th, 2010 3:02pm Report this commentI'm glad someone has finally mentioned the 'P' word. As the public is not outraged about what is, in reality the 'Privatisation of the NHS, I can only assume that they remain blissfully unaware of where this is all taking them.
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