Linear progress, zig-zagging or going round in circles? Calum Paton asks whether the Health Bill’s ideal of clinical commissioning can really deliver an improved era of healthcare after the years of false starts and rebadging.
The All Party Parliamentary Group (APPG) on Primary Care and Public Health has just published its latest report: “Were massive reforms necessary to save the NHS?” It contains a good old helping of motherhood and apple pie, concerning the need for patient self-help, prevention, integrated care (flavour of the month - literally) and the like. But it is the consensus which it detects - that the Health Bill’s aims may be worthy but that they could be met (and are being met) without ‘massive’ change - which requires critical comment.
At one level, who could disagree with this consensus, except those charged with defending the infamous bill and its strategy of “top down reform”? But then the cynic within kicks in: “hang on - when everyone agrees, they are usually wrong”. In a month when motherhood-and-apple pie (and especially the sweet taste of “integrated care”) has featured on more than one menu - the NHS Future Forum’s second set of reports spring to mind - it is important to challenge the conventional wisdom of the “London consensus” (as in, the English NHS as opposed to the other UK NHSs.)
Yet note the core assumption - that the Health Bill’s direction of travel is right, and the problem lies elsewhere, namely strategy and tactics. The APPG suggests that there are three forerunners to clinical commissioning groups - practice-based commissioners, world class commissioning and - earlier - GP fundholders. But it does not ask if there is aggregate evidence that primary care commissioning is a better alternative than other means of planning, funding and’performance managing services.
In its individualistic form, GP fundholding, born in 1991, bore little relation to CCGs. But it gradually evolved, for reasons of scale and politics, into Total Purchasing, from c.1995, bringing together larger groups of GPs buying all services for their populattions. The Total Purchasing Pilots (TPPs) were evaluated by the Department of Health, and the predictable findings were that: to do it well was expensive and took time; GPs did not generally commission secondary services well “across the board”, principally because they were not interested in so doing - with the exception of minority enthusiasts and entrepreneurs; and GPs were best at both commissioning and providing “extended primary care” (which the Health Bill does not allow them to do!) The evaluation did not compare GP purchasing, as it was then called, with alternatives.
In 1997, TPPs were the prototype for the new primary care groups (later PCTs), with New Labour’s policy retaining the purchaser/provider split and therefore evolving from the Tory reforms of the 1990s rather than rejecting them. But the high hopes for clinically-led commissioning exercised through the professional executive committees of the PCTs, which went national in 2001, were soon dashed through inertia and bureaucracy. In 2005, practice-based commissioning resurrected the idea of grouped practices buying services.
Like the TPPs, practice-based commissioners were responsible to their parent Health Authorities and so, some might say, not as bold as “autonomous” CCGs. But this ignores the political and managerial reality that CCGs will be responsible, like PBCs were, to a higher managerial authority - to the regional arms of the NHS Commissioning Board. Thus the usual suspects in new suits give credence to the WHO theory of NHS re-organisation: not the World Health Organization, but Pete Townsend in Won’t Get Fooled Again - “meet the new boss; same as the old boss”.
So the question for the government - why not just roll out PBCs again? - is a fair one, but one which would be answered, I think, to the tune that PBC was quickly discredited and that a new initiative was necessary. Yet a deeper question would ask, are you sure that primary care commissioning of any sort is the right answer; indeed, do you really know what the question is?
Most of us could agree that - whether it’s called commissioning (in order to savour of the market, as in England) or planning (as elsewhere in the UK) - the real need is for more effective identification, quantification and prioritisation of need. Hence World Class Commissioning, it is claimed by increasingly desperate defenders of a bad brief, can be better employed if clinicians are in charge. But this is hughly dubious.
WCC was not an evidence-based method of allocating resources to meet need, but a managerialist benchmark created and named by David Nicholson and Mark Britnell, then director of commissioning, to provide a basis for judging PCTs with the bite of Monitor’s authorisation process for foundation trusts. Indeed it became a ‘tick box’ i.e. you could be a good commissioner on paper and a bad one in reality, and arguably is little more than a management consultant’s slogan.
So there has been no logical, linear progress towards an “ideal” model of clinical commssioning. There has not even been a zig-zag in the right direction. There has been a fairly cyclical, even circular, move from yesterday’s trend to today’s, then tomorrow’s, then back again, with turnover so high in the NHS that a new name can disguise this depressing fact. Commissioning per se, never mind “GP” or “clinical” commissioning, is the dog which has not yet barked, over more than twenty years, yet has been given an expensive new kennel witnh a new name on the front every few years.
The London consensus - even in its non-political incarnations through the King’s Fund, the Nuffield Trust, the NHS Future Forum and now the All Party Parliamentary Group - thinks that improving commissioning and commissioning integrated services from competing providers is the answer. But how can we afford the capacity to have competing Kaiser Permanentes across England when what capcity there is is being sweated and, if possible, stripped out.
And how can we posibly believe that family doctors are the best people to oversee this, or that they want to, even if joined locally by retired hospital consultants who are thereby eligible (by virtue of not having the conflict of interest of working locally) to award a contract to the local provider? Those whom the Gods wish to destroy, they first make mad….
It would be nice if those seeking to hold the government to account, either intellectually or politically, could step outside the conventional comfort zone of policy.