GP commissioning: plus ça change?

Is it time to move beyond commissioning? This was the question posed by Dr Judith Smith  to the panel in a debate session at the Nuffield Trust’s annual Health Strategy Summit 2011.  The question arose from a cool appraisal of the research evidence on 20 years’ experience of NHS commissioning in England – evidence which points to very limited impact by commissioners on secondary care, and a struggle to make the shift to community-based care that has been long exhorted in policy.

Judith highlighted some persistent problems with commissioning identified in research:  asymmetry of information and power between commissioning organisations and providers; lack of sufficient high quality management and analytical support for commissioning; and difficulties in sorting out budgets and financial risk. Given this history, we are putting huge faith in GP commissioning, at a time when the economic environment is challenging, to say the least.

So what is needed if commissioners are to deliver the efficiency challenge? Whilst the evidence suggests that primary care-led commissioning has been effective at developing primary and intermediate care, it has struggled to make strategic changes to secondary care.  And implicit in any discussion of strategic change and efficiency savings is the spectre of hospital closure: in the longer term, we cannot sustain the current hospital system.

Difficult decisions will have to be made, and these will now fall to GP consortia.

There was much debate about whether there is a tension between a consortium’s role in buying from a local hospital and their role in changing the local configuration of health care.  And it was recognised that the narrative given to the public around changing hospital services needs to be carefully considered by all involved.

Rather than talking about hospital closures, we should explore how people feel about new models of care.  Furthermore, it was asserted that where GPs have stood up with commissioners in support of service change, hospital reconfiguration has been shown to be possible with public support.

Indeed there was some optimism that GP commissioning may be able to deliver change.  In the past commissioners have often struggled with clinical engagement – now clinicians can lead and own the process.  GP commissioners will look at the economics of commissioning in a different way – as small businesses they are more likely to use disruptive innovation, for example by commissioning more services with and from the third sector.

Despite this upbeat assessment from the panel, the delegates remained sceptical.  At the end of the session they were given four options for what commissioning might look like in 2015.  Nearly half thought we would have slightly more clinically-led PCTs running large deficits.  And to achieve those crucial efficiency savings?  Delegates thought something more akin to the old way of doing things was required.

In a survey of delegates conducted before the summit, stronger local performance management was the much-preferred lever for achieving efficiency savings, with few considering that GP commissioning on its own would be the answer.

And herein lies the conflict.  To make the transition to the new system, and engage GPs in the process, consortia will want flexibility and freedom. Whether the NHS is prepared to take that risk or will revert to central performance management type is as yet unclear, but this will be a key factor in determining the shape, and success of commissioning in the next few years.