The Conservatives and Practice-based Commissioning
Civitas, 8 October 2009
To anyone familiar with NHS policy of the 1990s, Conservative plans to reform PbC sound a lot like GP fundholding.
Shadow Health Secretary Andrew Lansley writes in today’s Health Service Journal: “As those in the closest regular contact with patients, GPs are well placed to commission the best quality services for their patients. We will hand them real budgets to manage the costs of their patients’ care.”
GP fundholding—part of Conservative NHS reforms of 1991—consisted of just this: actual budgets were given to primary care physicians who chose to buy a subset of elective care for their own patients. A few progressive groups of general practices volunteered for the experimental Total Purchasing Pilots (TPP), under which they were given additional responsibility for purchasing secondary and community care not included under the regular fundholding programme. It isn’t clear from Lansley’s description, or from Conservative health policy documents, which of the two the proposed arrangement would more closely resemble. The party’s published health plan states that GPs are ideally situated to ‘assess and anticipate an area’s burden of disease’ and that ‘GPs – rather than remote managers – should be responsible for reconciling the available resources with clinical priorities and patient choice,’ but where their commissioning responsibilities end and where those of primary care trusts begin is not explained.
What do we know about the outcomes of fundholding and TPP? Sadly, not much. The most common conclusion is expressed well by Smith and Wilton in a 1998 article in the British Journal of General Practice: ‘Evidence concerning the success or otherwise of general practice fundholding over the past six years is incomplete and mixed. The major deficiency concerns any effect on health outcomes that may be the result of fundholding. Until such research is conducted, the jury will have to remain out on whether fundholding has secured improved efficiency in the delivery of health care’. The policy’s removal in 1997 was purely a political move by Labour, which had spent years campaigning against the Conservative’s NHS internal market and all related policies.
Andrew Lansley continues in the HSJ: “With part of GPs’ pay dependent upon the results of their patients’ treatment, they will have a direct incentive to buy the most efficient services on behalf of their patients, because they will be able to keep any savings and use them to reinvest in care. Primary care led commissioning will provide the essential combination of clinical decision making alongside accountability for resources.” A major incentive in fundholding was the ability to keep almost all savings. Under current practice-based commissioning policy, GPs can still keep savings, but they must be reinvested into the practice, and the budget is ‘virtual’, meaning all money is actually kept with the local primary care trust (PCT).
The particularly interesting part is the proposed payment dependent on actual outcomes (not to be confused with the existing hospital funding scheme ‘Payment by Results’, which should more realistically read, ‘Payment by Output Quantity’). The Conservative health policy plan does not say much more about how they would implement such a programme, only that ‘the funding regime will reward success and encourage under-performing providers to improve.’
The proposal is already facing backlash; BMA chairman Dr Hamish Meldrum has immediately responded to say that handing all commissioning powers to GPs will create a conflict in their duty to patients.
I know some GPs who would jump at the opportunity to take on more commissioning authority and others who already find the idea of purchasing care completely overwhelming. If the Conservatives do go this route and have the opportunity to put these ideas into practice, I certainly hope they plan for the support GPs would need, and perhaps provide further guidance to collaborative GP organisations, which are more likely to be enthusiastic and able to take on such a responsibility than individual practices.