Author: Dr Judith Smith

Date: 22/04/2010

Organisation: Healthcare Republic

Extract:

As scathing attacks go, the House of Commons health committee's final report on commissioning in the English NHS before the general election was truly blistering.

Two decades since the Conservatives separated healthcare commissioning from its provision, the committee did not pull its punches and railed against the ineffectiveness of PCTs.

Lacking clinical knowledge and managerial expertise and prone to passivity, our PCTs do not have the clout to challenge more powerful hospitals over the services they provide. Or so the committee said.

The real issue is not whether they have failed but whether they have been given a fighting chance to make the radical changes to service provision 'strong' commissioning entails.

Other aspects of NHS reform, such as independent foundation trusts and a funding system that rewards hospitals for treating ever more patients, have constrained PCTs' ability to develop community-based alternatives to hospital admission.

Simply put, hospitals and other NHS care providers are too strong: they are often adversarial and do not pull in the same direction as commissioners.

That is why we need a fundamental realignment of healthcare delivery that places GPs and other clinicians at its heart.

This requires radical new approaches, not just to boost commissioning, but to streamline care delivery across primary care and in hospitals, to help people stay well and to reduce avoidable hospital costs.

What is missing in our health service is strong, clinically led commissioning. Policymakers and NHS leaders should consider new models that are led by GPs and other clinicians in primary care and hospitals.

These would need to deliver co-ordinated care for patients across different providers, particularly in the patient's home. This could help re-engage clinicians in managing services and securing more value for money - something that practice-based commissioning (PBC) has yet to achieve consistently.

Proposals

The Nuffield Trust and the King's Fund recently published two joint reports on the future of commissioning and integrated care. One option floated is to develop integrated care organisations (ICOs) led by GPs and other clinical staff to take responsibility for managing populations' health.

With a capitated budget for NHS-funded care, clinicians would have stronger incentives to provide the most cost- effective care.

This would encourage GPs and other clinicians - including hospital doctors - to streamline care and to be much more proactive in helping patients to stay well. Good examples are emerging and, while it is early days, these models could offer the NHS its best hope of reversing the upward trend in avoidable ill health and hospitalisation.

Would this be enough to make it worthwhile for GPs to become involved in service development in the way many did in the 1990s through GP fundholding, locality commissioning and total purchasing?

A strong incentive would be to hand PBC practices or consortia real, risk-adjusted budgets for certain or all elements of their activity, with the promise of keeping the savings they make to invest in patient care.

This would align financial risks with potential gains, providing a clear incentive for GPs and other clinicians. They would take responsibility for the health outcomes of their populations and take proper control of service planning, development and commissioning processes.

Achieving results

Making this happen requires the right incentives and careful consideration of the level of risk appropriate for these new clinical partnerships.

GP groups would need more management support, infrastructure, and incentives to engage clinicians in the community and, increasingly, in hospital-based clinical directorates.

PCTs - and perhaps also acute trusts - should be providing this support. However, the practicalities will be extremely challenging, given recent exhortations to reduce expenditure on NHS management by 30 per cent.

While there is no one model for developing local clinical commissioning for the future, the next generation of PBC groups or ICOs will be shaped by practical matters such as the population needed to assume financial risk of the budget, the size of organisation needed to attract relevant skills and infrastructure within increasingly constrained resources.

Of course, if this was easy to achieve it would have been done already. But unless the NHS gets to grips with this agenda, it cannot hope to respond to rising demand for care in a period of constrained budgets.

Read this article on the Healthcare Republic website

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