Handing real budgets to GPs: is this really the right approach?

Blog post

Published: 21/09/2010

Will GP consortia be able to achieve better value care and control costs in the NHS in England? This policy is the centrepiece of health secretary Andrew Lansley’s NHS reforms, and as we go into the autumn it remains the key point of debate (read our briefing on the health White Paper). 
Already Stephen Dorrell, former Secretary of State for Health (1995-7) and newly elected chair of the Health Select Committee, is asking the obvious: what is the evidence that GP commissioning will work after 20 years of being largely ineffective? The choice of commissioning for the first Health Committee of this government, plus Mr Dorrell’s obvious public scepticism about it, is the opening shot in what could become a battle.
There are at least two main issues. Let’s start where we are now: first can GP consortia develop adequately and achieve results? Second, is this really the right approach?
Earlier in May the Trust was privileged to host Prof. Larry Casalino from Weill Cornell Medical College, New York. Larry has spent 30 years working in primary care in the US and more latterly carefully charting the development of consortia of physicians groups. Larry’s observations about the policy to develop GP commissioning consortia were astute and sobering. Join us on 18th October for Larry’s John Fry Fellowship lecture on this topic.
If the NHS budget is protected at near ‘flat real’ growth as expected in October’s spending review, it is difficult to see how GP commissioning consortia will be able to contain expenditure any better than PCTs before them.
History shows us that practices were more able to use commissioning to improve primary care than shape hospital care, as outlined in our report, Where next for commissioning in the English NHS?, published earlier in the year. Yet the latter is exactly what is now needed since most NHS expenditure is in hospitals. GP consortia, probably at less than half the size of PCTs, with less developed infrastructure, and having to offer free patient choice, are surely going to find it tough going to influence hospitals, especially those financially stressed.
Which brings us to the second question: is this really the right approach? 
The principle of giving GPs, as other clinicians, budgets to manage is clearly a good one. The ripest area for enhancing value in health care is in emergency care, care of the elderly and people with long term conditions. Here, GPs need to work with specialists and patients to develop pathways of care to reduce avoidable ill health and use of care. Without this integrated working, there is frankly no hope of achieving the value and efficiency gains now needed.
In the US, vertically integrated care is now recognised to be the route to high value and efficient care, evidenced by results at the Mayo Clinic, Kaiser, Intermountain, and Geisinger. This is why the Affordable Care Act promotes the development of accountable care organisations, a subject which featured highly in our US/UK bilateral event on reform in Boston in July.
The former CEO of the Mayo Clinic, Denis Cortese, visiting us this month, was robust about the need for integration, and the experience at Mayo that is useful for us in the NHS. As he outlines in our latest videos, putting 80% of the NHS budget in the hands of GPs risks driving a wedge between primary physicians and specialists – the opposite of what is now needed.  
Achieving integrated care will take time, with many barriers to overcome, as shown in our recent analysis of sites trying to develop it. Despite national policy, there is growing development along these lines in the NHS, the US, and internationally – join us in Salzburg in November to discuss. Failure to understand this evolution will cost the NHS dearly.

Suggested citation

Dixon J (2010) ‘Handing real budgets to GPs: is this really the right approach?’. Nuffield Trust comment, 21 September 2010. https://www.nuffieldtrust.org.uk/news-item/handing-real-budgets-to-gps-is-this-really-the-right-approach