On the day that the Coalition Government published ‘Liberating the NHS: commissioning for patients’, I found myself here in Auckland as a keynote speaker at the joint conference of the Australian General Practice Network and General Practice New Zealand. These two bodies represent what in this part of the world is known as ‘organised general practice’ or in NHS terminology ‘GP consortia’.
Travelling to the Southern Hemisphere can be disorientating. Summer is replaced by winter, and the days are suddenly short again. What is however reassuringly familiar, both in New Zealand and Australia, is the talk of health system reform and efficiency, the future role of GP networks and organisations, and how far such networks should take on health planning and budget-holding responsibilities if they are to develop better integrated care.
Time and again here, I am being asked ‘what on earth are they doing in the NHS, giving budgets to GPs again for commissioning – isn’t that rather risky?’ To this, my response, as discussed by my colleague Ruth Thorlby when we were in the USA recently visiting medical groups in California, is that yes, there are clear risks in taking such an approach, and careful implementation will be needed if the next incarnation of GP commissioning can deliver where others in the UK and overseas have failed.
However, as I observe the Australians considering (subject to what happens in their upcoming elections) the development of a national system of ‘Medicare Locals’ – primary care planning organisations to sit alongside the long-standing Divisions of General Practice that have been fiercely clinician-led GP collectives for almost 20 years – I wonder if that is not more risky than what us Poms might be doing.
I have been warning Australian colleagues of the very real risk of killing off much of their extensive GP engagement in Divisions, based on what happened in the NHS when the imposition of PCTs effectively snubbed out the clinician engagement in commissioning that had been a hallmark of GP fundholding and total purchasing in the 1990s.
Here in New Zealand, the government is backing a number of highly ambitious proposals to build complex new primary care organisations, having sought expressions of interest from across general practice and other community providers.
Under the banner of ‘Better Sooner More Convenient’, these networks of providers (covering a population base ranging from 31,000 to over a million) are now trying to work out how they can deliver better integrated and more efficient local services, whilst preserving the vital clinician engagement that has been nurtured through the independent practitioner associations that have played a key role in New Zealand general practice for two decades.
This leads me to conclude that the great potential in the current NHS proposals for GP commissioning is the opportunity to rekindle the clinical engagement that was snubbed out in the late 1990s. The challenge for policy-makers is to enact GP commissioning in a way that excites and engages front-line clinicians, whilst assuring an appropriate degree of public accountability for holding such large budgets.
My hope is that in designing the new arrangements, we can look beyond our own shores to learn from both the successes and failures of colleagues in New Zealand, Australia, Canada and the USA – all of whom have experimented (and continue to experiment) with using organised general practice as the basis for planning and funding local health services.
To this end, the Nuffield Trust will be publishing a briefing paper in September that explores Californian experience of medical groups, and a monograph in December that examines the New Zealand IPA experience and what it has to offer the NHS.
So whilst the new NHS proposals are indeed risky, they also hold the potential for a new phase of real clinical engagement in service development, as long as we can focus on careful design and implementation of the new arrangements.
As the former captain of the Australian rugby team, Nick Farr-Jones, exhorted at the conference here yesterday – don’t get dispirited by constantly looking at the scoreboard, focus relentlessly on the detail of your game, and results will surely follow.
Smith J (2010) ‘GP commissioning viewed from down under’. Nuffield Trust comment, 28 July 2010. https://www.nuffieldtrust.org.uk/news-item/gp-commissioning-viewed-from-down-under