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.