A better direction for NHS commissioning?
Civitas, 29 October 2010
Yesterday, Civitas, in conjunction with the Manchester Business School, published this report, looking at the relationship between the size and performance of commissioners in the NHS. It found none, although both the domestic and international trend is towards larger commissioners, covering larger populations: the direct opposite to what is likely to happen under the Coalition Government’s White Paper on the NHS with the proposed move from PCTs to GP consortia. The evidence, in other words, doesn’t provide much in the way of support for the reforms to commissioning: reforms that are likely to be costly with uncertain outcomes.
Some of the wider points in relation to this are:
First, what evidence that exists on GP-led commissioning in the NHS comes from a different context to that proposed: one where GPs could volunteer to take on hard commissioning budgets for a sub-set of care, very different to now where every general practice must be part of a consortia and hold budgets, and the risk, for the vast majority of health care. In the United States, where the latter has been tried, only one in 10 associations succeeded both financially and in terms of improving patient care, according to the Nuffield Trust.
Second, as stated, it is likely that GP consortia will be smaller in terms of population capture than existing PCTs. While this may make them more local, it may also make them too small to commission effectively in terms of their ability to bring in alternative providers as a competitive challenge to acute trusts to up their game (a separate aim of the White Paper). Certainly, the international trend is towards larger, not smaller, commissioning organisations.
Third, one cannot and should not ignore the possible impact of such fundamental restructuring of commissioning at a time when the NHS faces its greatest ever productivity challenge: around 4-5% per annum over this parliament according to the King’s Fund/IFS. Such productivity gains are far in advance of what either the NHS (-0.4%) or private sector industry (+2.3%) have achieved in recent times and will only come about through competition and the fundamental reconfiguration of provision, led by effective commissioning. Yet past experience suggests effectiveness may fall, rather than improve, in the short-run following restructuring. When 203 PCTs were merged in 2006, performance on finance and quality of care dropped the following year; taking on average three years to catch up with the relative performance of those that weren’t merged.
Given this, there is also a very real risk that central control will be re-asserted in the interim period, carrying the danger that the restructuring will, ultimately, just lead to a re-invention of the wheel.
So, is there a better way: a way in which we might achieve the benefits of improved performance and increased localism and clinical input, without another round of top-down restructuring? Here’s one suggestion. First, the shackles should be taken off PCTs. They should be freed of interference from Strategic Health Authorities (which the White Paper is right to abolish); and assessed by the outcomes they achieve not the processes they follow. Second, to increase clinical input, GPs should be given increased statutory influence over PCTs and, according to a rules-based procedure, able to take them over. Third, there should be a rules-based failure regime: a 90-day notice period where other PCTs or entrepreneurial groups of GPs have the option of taking over a commissioning organisation that is failing. Fourth, PCTs should be free to change organisational form and governance structures: to merge and de-merge and, more radically, form as mutuals or cooperatives.
This should then permit a series of locally-initiated experiments in commissioning that could be learnt from, rather than further centrally-initiated engineering that has failed the NHS throughout its history.