Dr Rachel Joyce was Conservative candidate at the 2010 General Election in Harrow West. She is also a doctor and has worked as both a Director of Public Health and a Medical Director in the NHS.
The reason we need GPs in commissioning
There’s a saying in the NHS that GPs spend all of the NHS budget (and more) with the stroke of a pen – either by writing a prescription or by writing a referral. It has therefore long been recognised that the answer to ensuring value for money for the NHS budget lies with GPs and their actions – hence fund holding, then Primary Care Groups, Primary Care Trusts, Practice Based Commissioning (PBC), and now GP consortia. Trying to change clinical practice to improve outcomes and provide value for money without GP support would be like fighting against the tide. Areas that have successfully engaged GPs – such as Cumbria – have already done well under PBC arrangements. The question is whether these latest reforms will work to encourage those GPs who have so far been reluctant to get involved to do so.
Conflicts of interest
Involvement of GPs is not however enough – what is needed is for GPs to sign up to commissioning high quality value for money services. GPs are independent providers who have done very well out of Labour’s changes. Generally they now earn more from the NHS than hospital consultants, with one family doctor now on a salary of over £500,000. Many GPs have financial interests not just in their own practices, but also in services that they may potentially commission. A recent report by the GP magazine Pulse reported that almost a quarter of consortium board members have some kind of interest in private providers, with others either shareholders or advisers. One GP in 10 on the boards of new commissioning consortia also holds an executive-level position with a private provider. There are already many examples of conflicts of interest, including reports of overt lobbying to continue with services that they are shareholders in – even if they don’t demonstrate value for money.
There are countless examples of pressure to pay GPs extra for services that are arguably already paid for once, twice or more times in the GMS contract and the Quality and Outcomes Framework (QOF). This is why it is absolutely clear that decision making in GP consortia need to be transparent and open to scrutiny, with safeguards against these conflicts of interest. A review of GP payments and incentives is needed if consortia are to provide value for money in the future.
Commissioning by anecdote vs understanding the whole pathway
GPs see only one side of the NHS – their own distinct catchment population, seeing common illnesses regularly, and hardly ever seeing rarer conditions. Most don’t have the depth of understanding or experience of rare conditions that hospital consultants have. There is a tendency for clinicians in all specialities to see the NHS through their own experiences, when the bigger picture, or the whole pathway can be very different. Under the current proposals public health doctors would be moved out of the NHS and hospital clinicians would not be involved in consortia decisions. The Health Select Committee Report in contrast recommended that both should be on consortia boards. Public health consultants provide the information and needs assessment, the evidence reviews on what treatments work and the health economic (value for money) analysis that informs commissioners. GPs don’t have the time or the training to do this. One way of addressing the need for clinical involvement, GP accountability and securing an unbiased whole pathway approach would be to widen the use of clinical networks, which in heart disease and cancer care have recently delivered excellent results. Clinical networks involve GPs, hospital consultants, public health, pharmacists and other specialists as well as patients. Each specialist group adds value to the development of services and pathways, and holds in check the tendency of each other to prioritise the issues that reflect their individual anecdotal experience. Delegating programme budgets to these networks – with appropriate accountability arrangements, could be a model for clinical led commissioning.
Size is important
Andrew Lansley talks about each patient’s GP being able to sort out a pathway of care for their patients. Small consortia would allow a closer relationship between patients and GPs in the commissioning process. However not every GP wants to get involved in the day-to-day commissioning and contracting arrangements with other providers – and some could be driven to early retirement if forced to do it themselves.
Hospitals and other providers have to employ many more managers when they have to deal with many more commissioners, and each commissioning consortia needs its own set of managers, and has to pay for the time of the GPs who choose to get involved in the detail (and as stated earlier, GP time is very expensive). Small consortia will therefore be significantly more expensive to run than larger consortia. McKinsey warns that consortia of only a 100,000 population are much more likely to run at a deficit than those of 300,000 – with those serving populations of 1 million very unlikely to run deficits.
Pooling of risk is also important. Both the Royal College of GPs and the BMA’s GP committee believe consortia should cover populations of around 500,000. Foundation Trusts and private providers are often large with significant management and legal resource. Experience to date has also shown that small PCTs (such as in London) have often had little clout when commissioning large Foundation Trust hospitals, and as a consequence have often struggled to achieve the changes they need. So size does matter – larger consortia will be more efficiently run, will have more clout, but will be more distant from their patients.
The problem with management
It is received wisdom that there are too many managers in the NHS. Until Sir Roy Griffiths recommended the introduction of general managers in 1983, the NHS had pretty much been run on the basis of consensus. Centralised requirements, measurements and targets have increased exponentially, and the purchaser/ provider split means managers are needed on both sides. Until the Department of Health starts to really cut down the number of requirements it won’t be possible to make really significant inroads on management costs. If the government is serious about reducing the burden of bureaucracy and wasteful management a “one in, two out” requirement for NHS red tape rules would make a real difference.
Good managers are invaluable, and poor managers are a positive hindrance. Although there is a management training scheme – which is very competitive – most managers do not have formal training, and the quality of managers is extremely variable. GPs are untrained and inexperienced in commissioning, and so it is vital that they have support from high quality managers and public health doctors. The costs of this reorganisation including redundancy payments are estimated to be in the order of £1.2 billion. Many of these managers will be re-employed by consortia who initially underestimate how many managers they will need. Close attention needs to be made to ensure that good managers are not lost and that those who receive redundancy payments do not re-emerge as NHS employees soon afterwards.
Many argue that the natural evolution of the NHS – getting more GP engagement – didn’t need government legislation or such a large reorganisation and cost. This may or may not be true, but most agree GP involvement is invaluable, but they are not however the only clinicians that need to be involved to ensure high quality, cost-effective services. Clinical networks represent the best model for clinician led commissioning. GPs’ conflicts of interests, payment systems and accountability have to be addressed and government needs to significantly reduce the administrative burden it places on the NHS.