The Thatcher government introduced the purchaser-provider divide in 1991. Ever since governments have been rebranding and “redisorganising” the structures of what are now primary care trusts. However these reforms of structure have had little impact on process and outcome. PCTs are viewed as largely feeble organisations that facilitate the continuing inefficiency in provider performance. Consequently the Department of Health wants to invest in world class commissioning and transform PCTs into robust agents of change.
This ambitious concept requires PCTs to manage activity and clinical costs with real time data, and increasingly supplemented by patient reported outcome measures.
It requires them to hire in specialist analysts, particularly the data analytic skills of statisticians and economists. Only with these capabilities and sharp incentives to alter inefficient behaviour will PCTs be able to hold providers to account and mitigate the manifest inefficiencies of the NHS, well known for at least three decades and exemplified by data showing the delivery of different bundles of care to patients with similar needs and characteristics.
This policy will be very costly in terms of developing data, its analysis and incentivising change in the NHS. They are all welcome but do we need PCTs to implement this change agenda?
Providers create most of the data that will be used by PCTs to manage performance. They too will need to invest in the analysis of activity and service delivery cost data. They will be obliged to develop PROMs particularly if PCTs threaten to withhold or reduce tariffs payments for poor outcome performance. Are PCTs needed or are they merely duplicating the efforts of providers?
The Scots and the New Zealanders abandoned the purchaser-provider split some years ago, but their system performance is hardly exemplary. However health maintenance organisations such as Kaiser Permanente in California appear to achieve good results without the “benefit” of the purchaser-provider split.
The HMO model and its focus on integrated service delivery also brings into sharp relief the UK division between primary and secondary care. The Government’s policy of rebranding GP fund holding in England as practice based commissioning has given indicative budgets to primary care providers. However this gives few incentives to economise and create cost effective pathways for patients needing integrated packages of primary and secondary care.
Perhaps it would be better to allow PBCs to merge with local hospitals and create HMO style provider capacity? Or can local collaboration between GPs and hospitals generate integrated care, and if so why do we need PCTs as they may be irrelevant to such potentially useful cooperation?
Could world class commissioning allow experimentation with these alternative institutional arrangements without going for another system change? This requires boldness in Whitehall and increased regulatory rigour.
The remarkable similarities between the policy focus of today and 1976 is epitomised by the 30 year old document Priorities for Health and Personal Social Services. This lamented the variations in clinical practice e.g. the failure to develop day care and differences in length of stay for common procedures and other performance variables.
Data similar to this is being reiterated by Government, in particular the NHS Institute for Innovation and Improvement, and is common across all health systems. Better activity, cost and outcome data will make variations in clinical practice more transparent but how can this knowledge be used to induce change and translate 30 year old evidence into improved patient care?
We do not know the answer to this question. Putting your money on one horse, “world class commissioning”, is surely risky. Why not let “a thousand flowers bloom” thereby creating different routes to common regulatory goals? This would create a nice research environment which facilitates learning from institutional change rather blundering along in the one size fits all mode.
Government wishes to improve patient care. This requires improved data, its analysis and its implementation into managerial and clinical practice. The crucial determinants of success are clear: simple policy goals and robust incentives to encourage radical change. Experimentation with a diversified approach involving integrated HMO-type structures and the demise of some PCTs is worthy of consideration.
Alan Maynard
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