GP commissioning in the NHS in England: Ten suggestions from the United States

A leading scholar from the US sets out what the NHS in England could learn from the US experience of doctor-led commissioning.


Published: 13/06/2011

ISBN: 978-1-905030-46-0

Download the Viewpoint [PDF 422.2KB]

As the NHS in England prepares to transfer responsibility for around 60 per cent of its budgets to GP commissioning consortia (now clinical commissioning groups), the degree of financial risk that will be faced by these groups is much wider in scope than anything seen before in the NHS. It is in fact closer to the risk that has been held by some doctor-led groups and networks in the US, which have contracted with insurance plans to manage the care of patients within a fixed annual budget.

This Viewpoint distils the learning from the experience of these commissioning models by Dr Lawrence Casalino, who, as the current Nuffield Trust John Fry Fellow, spent six weeks in England recently exploring commissioning in the NHS. Dr Casalino provides a brief history of risk contracting in the US; describes the different models of physicians contracting with health insurance plans; and sets out ten suggestions for clinician-led commissioning in England, based on the US experience.

There will be a great many ways to get the new system wrong and very few ways to get it right, with significant consequences if failure were to occur

Dr Lawrence Casalino

More than 1,500 doctor-led networks and groups (so called ‘independent practitioner associations’) emerged across the US from the mid-1980s onwards to contract with insurance providers and take responsibility for fixed budgets with which to deliver their patients’ care. Dr Casalino states that only a small proportion have proven successful at managing the risks involved.

Dr Casalino attributes the failure of many independent practitioner associations to:

  • A lack of strong clinical leadership; under-investment in the management and infrastructure necessary to handle financial risk on this scale;
  • The political backlash over the perception that primary care physicians were profiting from their role as ‘gatekeepers’; 
  • Increasingly robust negotiating stances adopted by hospitals and specialists; 
  • Insurers’ tendency to reduce budgets progressively without accounting for influxes of sicker patients.

His analysis points strongly to the need for a well coordinated system of incentives both within clinical commissioning groups and between those groups, hospitals and the NHS Commissioning Board.

GP commissioning in the NHS in England: Ten suggestions from the United States will be of interest to policy-makers, NHS commissioners and researchers.

Suggested citation

Casalino L (2011) GP commissioning in the NHS in England: Ten suggestions from the United States. Viewpoint. Nuffield Trust.