Beyond practice based commissioning

With the NHS facing up to one of the most significant financial challenges in its history, it is vital that clinicians, especially doctors, are engaged in decisions about how patient services are designed and delivered and how NHS money is spent.

The challenge is to build on what has worked with PBC and find ways to entice many more clinicians into taking responsibility for managing resources

But while much debate has focused on the problems and barriers facing practice based commissioners - such as lack of engagement among clinicians and bureaucracy when it comes to approving business cases - little attention has been devoted to how we might build on the pockets of innovation and progress that GPs in some areas are driving forward.

With PCTs often struggling to make significant and strategic change in how services are delivered - for example, the Audit Commission recently reported on the lack of progress in shifting care from hospitals to the community - the time is right to come up with new solutions, and specifically how to breathe new life into clinically led commissioning.

Local partnerships

We believe one part of the solution lies in multi-specialty groups of clinicians – for example GPs as well as hospital-based and community specialists – joining forces to form new organisations, what we call local clinical partnerships.  These groups would assume a real budget on behalf of their local population, along with responsibility for designing, delivering and commissioning some or all local health services.

What’s in it for clinicians? For a start, as well as being handed real budgets, they would have responsibility for the health outcomes of their local communities. They would be able to take “make or buy” decisions, doing what clinically led organisations do best – developing improved and extended community-based care for local people, and using this as the basis for commissioning specialist advice, diagnostics and care beyond what the local clinical partnership itself could provide.

The partnerships would comprise a group of clinicians, and in most cases would be doctor-led, although they would have the active involvement of nurses from primary and community care, pharmacists and allied health professionals. As well as generalists, they would increasingly include specialists who would be contracted to the organisation from local foundation trusts, other acute trusts or community provider agencies, employed by the partnership, or engaged in the organisation as partners.

We know the Conservatives, if elected, would most likely make handing hard budgets to clinicians a central plank of their health reforms so, politically, this idea is gaining momentum.  What is now needed, and what our new paper seeks to provide, is an articulation of how such budget-holding by GPs and other clinicians could be made to work, both in terms of incentivising clinicians to take such roles, and in addressing the financial and service quality challenges ahead.

Virtual to vertical

The crucial difference between this model and what has gone before is the fact that local clinical partnerships would bring together specialists and generalists eventually in the same organisation. There may be a pragmatic and workable migration path – from virtual to vertical integration, from integrated care across a service, specialty or department, to full organisational merger. 

There is, of course, little appetite, politically or within the NHS, for further large-scale policy upheavals, but we believe these new organisations could evolve an organisational form relevant to their local scope, size and history. Foundation trusts, social enterprise models, and multi-professional partnerships show particular promise. There is no one model that suits rural Norfolk or inner city Birmingham alike – diversity in evolution will be key.

From our research, we know that these organisations show promise in a number of international health systems, where clinicians form themselves into groups that manage and develop the provision of local health services, typically under contract to local commissioners, and often in a situation where there is competition for patients or members.

The time is ripe to move beyond practice based commissioning. The challenge is to build on what has worked with PBC and find ways to entice many more clinicians into taking responsibility for managing resources, shaping local health services and improving health outcomes.   

While there are challenges in making this a reality in the UK, the majority of the policy makers, practitioners and managers who were involved in helping to shape this report published by the Nuffield Trust and NHS Alliance have emphasised the potential of local clinical partnerships as a way of starting to bridge the primary-secondary care divide in the NHS, and develop new forms of care that are fit for the financial and health challenges ahead.

Beyond Practice-Based Commissioning: the local clinical partnership, by Dr Judith Smith, Julie Wood and Jo Elias, is free to download from www.nuffieldtrust.org.uk/publications or www.nhsalliance.org