It has been very well advertised that the Health and Social Care Act 2012 places GPs more at the centre of the health care landscape. That was the explicit intention of the Government. GPs have always combined a vital clinical role with a (related) role of gate-keeper into the wider health care system.
The Act has given them an even more prominent role by handing a large proportion of the budget for health care spending over to clinical commissioning groups (CCGs) which GPs run. The importance of GPs in how health care evolves was emphasised by the importance given to CCGs in the recent review of the Fair Playing Field by Monitor and in the various reviews and initiatives launched by NHS England and Monitor in recent months.
In light of the importance of GPs as clinicians and now also as NHS managers and budget holders, the recent Nuffield Trust and Institute for Fiscal Studies (IFS) event was very well timed. Amongst other topics, the seminar discussed papers that examined what could be said empirically about GP performance.
Competition – and the potential for competition – creates another type of incentive for GPs
GP performance under the Quality and Outcomes Framework (QOF) has long shown that they score very well against the particular categories against which they are judged. They very quickly adjusted to the QOF when it was introduced to maximise their points under the framework. Some have taken that as evidence of how responsive GPs can be to messages and incentives about what type of care and areas of treatment should be of greatest focus.
Competition – and the potential for competition – creates another type of incentive for GPs. There is some evidence that GP practices do respond to the potential for patients to switch away from their practice and the desire to attract new patients.
Despite the very limited role for this type of competition to-date, one paper presented at the event suggests a link between the choices made locally by the public registering at a GP practice and relevant measures of quality. This provides evidence that people do care about many aspects of quality and might exercise their choice of GP more widely, and help create quality improvements, were it allowed.
A more subtle issue arises as GPs assume a greater role as both clinicians and commissioners: the degree to which their interests are aligned to those of their patients.
Financial advisers were raised as an example of one market where we may have witnessed some divergence between the preferences of the ultimate customer and of the intermediaries (the financial adviser).
Where the GP is acting as a guide or intermediary for a patient (eg in their choice of treatment, their choice of secondary care or other provider) it is important that their criteria for offering choices and guiding decisions matches as closely as possible the criteria of the patient in front of them.
One of the papers presented uses existing data and econometric models to try to understand the degree to which patient and GP interests are aligned. This work is at an early stage but could provide genuinely new insights into an area of increasing importance for patients and the public.
Economists are still at an early stage of modelling and trying to understand what drives performance and improvements for patients and the public in GP practices. We are beginning to see the leading thinking and research in this increasingly important area. I, and many others, wait with interest the emerging findings from this research.
Matthew Bell is Director at Frontier Economics. Please note that the views expressed in guest blogs on the Nuffield Trust website are the authors’ own.
Bell M (2013) ‘Competition – an incentive for GPs?’. Nuffield Trust comment, 24 September 2013. https://www.nuffieldtrust.org.uk/news-item/competition-an-incentive-for-gps