19 January 2011

Substantial investment in leadership, management and IT combined with a focus on helping GPs to work in new ways and collaborate more closely with their specialist colleagues is vital if the Government’s plan to hand control of NHS budgets over to groups of GPs is to succeed.

This is the verdict of a report published today by the Nuffield Trust, which examines the American experience of handing the equivalent of commissioning budgets to doctors over the past 20 years. Senior researchers from the Nuffield Trust visited a number of medical groups led by doctors in California and they argue that the experiences of these organisations reveal important lessons for the NHS in England as the Government prepares to transfer control of £80 billion of the NHS budget to GP consortia.

In the US, up to 2,000 doctor-led networks and groups emerged across the country from the mid-1980s onwards to contract with insurance providers and take responsibility for fixed budgets with which to deliver their patients’ care. Only a small proportion of these groups have survived to the current day.

The US experience shows that holding risk-bearing budgets can motivate doctors to deliver efficient, coordinated care that reduces avoidable and repeated admissions to hospital. However, to achieve this, the groups had to ensure that primary and specialist doctors cooperated closely and were able to invest in a range of high quality/innovative services that offer alternatives to hospital care, particularly for older patients with chronic conditions. The US experience also shows that those groups which initially underestimated the importance of investing in management support - including data and IT systems, experienced analysts, and other management and financial expertise - struggled at first to manage their responsibilities effectively.

The Nuffield Trust report concludes that there are clear risks of introducing GP commissioning when the government has placed such a strong emphasis on reducing management costs, and when proposals to develop more extensive co-operation between primary and secondary care remain under-developed.

Report lead author Ruth Thorlby, Nuffield Trust Senior Fellow, said: ‘The message from the US is unequivocal – many English GP consortia will really struggle unless there is a relentless focus on securing and sustaining high-quality leadership and substantial investment in management that can work with key stakeholders and develop strategic commissioning plans that drive innovation and change. More effective collaboration between local clinicians is also crucial.

‘However, in a constrained financial environment this investment is likely to prove hard to justify and the temptation will be to avoid investing in activities unrelated to the ‘front line’. This would not only compromise the clinicians committing time and energy to GP commissioning but, more importantly, could mean a lost opportunity for better coordinated and more clinically-led service improvement, and in particular a reduction in avoidable hospital admissions.’

The Nuffield Trust report, GP commissioning: insights from medical groups in the United States, by Ruth Thorlby, Dr Rebecca Rosen and Dr Judith Smith, concludes that several fundamental factors must be in place to make the reforms in England a success, including:

  • Management and IT: the US medical groups significantly underestimated the importance of high quality and professional management support in the early days of their development. The US groups spend around 15-20 per cent of their income on IT and management support, although some of this covers contracting and negotiating with multiple insurance companies. Continuity of medical and general managerial leadership was considered crucial to their financial survival and the development of robust relationships with secondary care.
  • Integration of primary and secondary care: the US experience shows that integration of primary and secondary care was seen as vital to the delivery of efficient high quality care, and all of the groups visited by Nuffield Trust had consultant medical staff employed within, or contracted to, the medical group. The US groups also encouraged specialist staff to work cooperatively with primary care colleagues to ensure that referrals were appropriate and to help reduce unnecessary diagnostic tests.
  • Peer review of doctors with incentives for high quality care: all of the US groups in this study scrutinised closely the performance of their doctors by using peer review of their performance data, supplemented by financial incentives for the doctors based on quality measurements. These financial rewards were not however based on measures such as rates of referral to secondary care, for there was an explicit desire to avoid conflict between the clinical decisions made by a doctor for patients, and the wider business interests of the medical group. In the context of GP commissioning in England, the question of how commissioning incentives should be used to influence clinical practice has not yet been resolved.

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