Published: 21/10/2004, Volume II4, No. 5928 Page 12 13 14 15
With the arrival of practice-led commissioning, primary care trusts are already being written off in some quarters.And despite high-level assurances that the future of PCTs is assured, many commentators believe that their streamlining is inevitable in a climate in which cutting bureaucracy and empowering clinicians scores political points.
Mary-Louise Harding opens our four-page special by assessing the tensions inherent in the new environment. Opposite, in a major new report from the Health Foundation, Richard Lewis and colleagues examine the impact of primary care-led commissioning and ponder how commissioning might best develop in the future
As soon as it became clear that the government intended to let GPs reclaim direct power over NHS purchasing, it seemed that the obituaries of primary care trusts were already written.
A U-turn had been performed, fundholding was coming crashing back, and, with PCTs viewed by some as having failed to prove themselves to be effective commissioners, the trusts would quickly wither and fade away.
Rumours that 304 PCTs would be cut by 50 per cent and - in the most radical suggestions - reduced to as few as 60 over the next five years began to circulate.
HSJ's conversations with those well placed to influence the new direction of commissioning suggest the situation is much less clear cut. Most are emphatic that PCTs still have a vital seat at the table. However, others are clear that the implication of practices adopting more of the commissioning role previously undertaken by PCTs, taken together with the growing pressure for trusts to control costs by merging management functions, is that the number of PCTs will - and should - be reduced.
This week's HSJ's survey of PCT chief executives confirms a strong belief that significant rationalisation of back-office functions is likely during the next 18 months (see The HSJ Barometer, page 23).
These tensions are heightened in the run-up to an election in which the government is seeking to show it is creating an NHS free from excessive bureaucracy.
Within government, those who share the prime minister's desire to reform the public sector see practice-led commissioning as a powerful way to unleash the entrepreneurial forces within the GP community.
But the Department of Health is concerned that commissioning reform must take place in a broader and less rapid fashion. However, although the DoH is emphatic about not setting a target on rollout of frontline commissioning, sources close to the policy state that there will be 'indirect pressure on what is considered a reasonable time frame' for PCTs to introduce practice-led commissioning.
National primary care director Dr David Colin-Thomé is emphatic that PCTs are here to stay. 'We are not getting rid of PCTs; we need them very strongly, but we are asking them to commission in much more radical ways than we previously have.
'They will only be able to do that through clinical engagement.
Giving GPs a budget, indicative or otherwise, gives them an incentive to get involved in redesigning care, especially those that haven't wanted to join professional executive committees.
'Some PCTs may see it as a threat, and some practices may be tempted into adversarial relationships with PCTs. But we are keen for [practice-based commissioning] to be a way of building effective relationships.'
South Yorkshire strategic health authority chief executive Mike Farrar, who led the GP contract negotiations for the NHS Confederation, is also clear that PCTs should not be consigned to history. He adds that the increased role of practices is not a catch-all answer for the shortcomings of NHS commissioning, some of which is - and should be - tackled by organisations able to serve larger populations.
'We need competent PCTs and competent practices. But we shouldn't be doing this as a way of avoiding the issues that need to be addressed in getting [all] organisations [which influence commissioning] up to a level of quality.
'The system between practices, PCTs, strategic health authorities and the DoH is a bit like a Newton pendulum and the ball is constantly going between them. If We are swinging the ball towards practices, it might impact on PCTs, but it will also have an effect on SHAs and the DoH.'
Mr Farrar says PCTs which fear merger should take heart from the apparent focus on strengthening relationships with practices.
'The larger the PCT, the more difficulty it has in building key relationships with practices. So if a PCT proposes to become larger, can it prove it has its relationships with practices sorted? If it still has issues, those are not going to be solved by getting larger.'
Dr Colin-Thomé cites North Bradford, East Devon, and South Hams and West Devon PCTs as examples of how commissioning can be effectively organised between trusts and practices.
Meanwhile, Mr Farrar is enthusiastic about a model based on groups of practices, representing a population of 20,000-30,000 designing, for example, chronicdisease management services, with resources procured by PCTs.
This is close to the locality commissioning suggested by many as the fairer alternative to fundholding in the 1990s. The greatest champion of this model is the NHS Alliance and its chair Dr Michael Dixon. 'If over the next five years we get robust commissioning systems bringing practices together, we will need to look at having larger PCTs that may even replace the need for SHAs, ' he says.
Dr Dixon's view is shared by Professor Chris Ham, until recently director of the DoH strategy unit. He believes postelection structural reform is inevitable: 'There will be an early move to streamline the number of PCTs, and what we will probably end up with is something like eight or nine health authority bodies to act as intermediaries between the DoH and PCTs.'
But he warns against the assumption that practice-led commissioning will automatically mean a reduction in PCT numbers. 'Given all the noise about bureaucracy and management costs, It is likely the government will want it both ways - tight on management and bureaucrats in the system, but with strong, effective commissioning models, too.'
However, Professor Ham stresses that practice-led commissioning will require more management capacity in PCTs, not less, 'because GPs who have the kinds of [commissioning] skills We have seen in North Bradford are not common across the NHS.'
Professor Ham, now at Birmingham University's Health Services Management Centre, suggests the situation might be made even worse through a lower-than-expected take-up of GP commissioning.
'Are practices equipped or willing? If you look at the new general medical services contract, There is plenty of opportunity for GPs to maximise their income.
So rational GPs will want to put effort into that rather than practice-led commissioning.'
NHS Confederation primary care lead and former Salford PCT chief executive Edna Robinson warns: 'We are talking about a set of [commissioning] transactions that will be much more complex to deliver at a practice [than at PCT] level, and [the policy] assumes a level of interest and willingness that may not be a given.
'So if it is inevitable that PCTs will be expected to merge management functions, we could end up with areas that have macrocommissioning PCTs and no practice-led commissioning.'
See The HSJ Barometer, page 23.
There is general agreement among the major political parties that the commissioning of health services must be, to a degree at least, 'primary care-led'.
Exactly how primary care clinicians are to influence the commissioning process, however, has been more contentious. A broad range of different approaches has been spawned and continues to evolve.
Examples include GP fundholding, 'total purchasing', GP commissioning pilots, primary care groups and trusts in England, local healthcare cooperatives in Scotland and local health groups and boards in Wales (see box, page 15).
Recent research funded by the Health Foundation has examined primary care-led commissioning in the UK to understand what its impact has been and how commissioning might best develop. The research was informed by a review of literature, interviews with key clinicians, managers and commentators and two stakeholder workshops.
1While there may be political consensus in Westminster that primary care-led commissioning is an appropriate direction of travel, there is little substantive research evidence that demonstrates that it (or indeed any other commissioning approach) impacts significantly on the way that secondary care services are delivered.
However, research into some of the variants of primary care commissioning such as fundholding, total purchasing, GP commissioning pilots and primary care groups suggests this type of commissioning yields at least some positive effects, including greater responsiveness of services (such as shorter waiting times for treatment); greater availability of practicelevel services; new forms of peer review and quality assessment; innovations in longstanding working practices and improvements to prescribing.
It is also clear that for primary care-led commissioning to be effective, a number of organisational and contextual characteristics must be in place.
For example, adequate management support and timely information are important prerequisites. In addition, meaningful clinical engagement in the commissioning process is crucial.
Research also serves to highlight issues that have proved problematic. Primary care-led commissioning organisations have often struggled to engage patients and the public in their work. Constant reorganisation has produced a highly unstable environment that has inhibited development and made it hard for primary care-led commissioning to prove its worth.
Primary care-led commissioning should not be considered in isolation from other approaches.
Rather than offering an alternative to commissioning models that are not based on primary care involvement, it is part of a broader continuum from which different (and complementary) options can be selected. Such a choice should be guided by the local environment and service configurations. The need to commission services at different 'levels', ranging from the level of the individual patient to that of the national population, will suggest different organisational options for the commissioning function.
A range of different approaches has been identified in the research. Each has been broadly aligned with the different 'level' at which services might be commissioned (see figure, opposite above). The key challenge for clinicians and managers is to select the right mix of commissioning approaches to suit local circumstances. A number of different criteria were identified by the research team to enable a systematic assessment of different commissioning approaches. These criteria encompassed the ability of any given commissioning approach to:
shape different types of services (for example, primary care, elective surgery, tertiary care and public health);
offer a degree of choice of provider, contestability and responsiveness;
manage budgets and financial risks;
minimise transaction costs;
develop and sustain clinical engagement;
address health needs and inequalities;
improve and govern clinical quality.
Viewed against these criteria, the different commissioning approaches reveal their strengths and weaknesses. For example, single practice-based commissioning may prove particularly effective for primary, elective and some other acute care and may offer a high degree of choice, budget management and clinical engagement.
However, it is likely to be far less effective in relation to tertiary care or public health and may suffer high transaction costs. It could also prove relatively ineffective in addressing inequalities due to its inherent variability. In contrast, multi-practice or locality commissioning approaches could improve performance in relation to service inequalities and transaction costs and may increase the range of services that could sensibly be tackled by primary care-led commissioning.
However, the trade-off for these benefits may be a lower level of choice, contestability and responsiveness.
Commissioning approaches operating at a higher level of the health system, such as a 'lead PCT' or national commissioning arrangements, are clearly more effective in relation to highly specialised care or accident and emergency services.
However, they are far less likely to be effective in terms of clinical engagement and choice and contestability.
Ultimately, a simple three-step analysis can be applied locally to obtain the right mix of commissioning approaches and to design a system of commissioning that maximises performance across the broad range of services:
Step one: analysis of the service to be commissioned - is the service simple or complex, are there opportunities for choice and contestability?
Step two: analysis of the local context and environment - is there already a choice of provider of this service, are patients likely to be willing and able to travel if non-local providers are available?
Step three: analysis of the proposed commissioning model against the performance criteria above (and any other criteria thought important locally).
Interviews and stakeholder workshops undertaken as part of this research revealed an increasing interest in using models of service integration that are not in themselves commissioning models and bridge the commissionerprovider separation.
For example, there was a view that new managed care approaches to the delivery of chronic care were closely related to more 'traditional' forms of commissioning - distinguished by the close collaboration between health planners and clinical providers.
The approaches included care pathway commissioning, which can be used to facilitate disease management across the primarysecondary care interface and to care for groups with complex health and social care needs.
One example is the Evercare pilots in England, which are based on a public-private partnership between PCTs and UnitedHealth Group, a US managed care provider.
Another example is the Scottish managed clinical networks.
These are broad networks of clinicians co-operating to coordinate, and thus improve, care for people with chronic illnesses using locally developed protocols for care. The interests and concerns of clinicians drive them, but active public and patient involvement is required, as is a concern to use resources effectively and efficiently.
So what are the main messages of the research? First, there is scant evidence that any particular commissioning approach, whether 'primary care-led' or not, has made a significant impact on the way hospital care is delivered except in relation to waiting times for treatment.
However, evidence does suggest that primary careled commissioning is effective in developing primary and intermediate care and in making elective hospital care more responsive.
Second, primary care-led commissioning has a place within a broader continuum of commissioning approaches, but that it is important to get the right blend of approaches that suits local circumstances and values.
Third, the turbulence experienced by commissioners has been harmful and they need stability to develop their craft.
Fourth, commissioners need new and more advanced forms of support if they are to challenge the dominance of hospital providers. This is likely to include skills in risk stratification ofpatients, analysis of quality and outcomes and predictive modelling for high-use patients.
Fifth, commissioning organisations must be given enough freedom to develop local as well as national commissioning priorities. This is vital if clinicians are to feel engaged with the commissioning agenda.
Finally, it is imperative that there is a more systematic assessment of the impact of different models of commissioning and of experiments in integrating commissioning and provider roles.
The diversity of models now operational within the UK presents an excellent opportunity.
Richard Lewis is visiting fellow at the King's Fund, Judith Smith is senior lecturer at Birmingham University's Health Services Management Centre, and Nicholas Mays is professor of health policy at the London School of Hygiene and Tropical Medicine.
Definition of terms 'Commissioning led by primary healthcare clinicians, particularly GPs, using their knowledge of patients'needs and of the performance of services, together with their experience as agents for patients and control over resources, to direct the heath-needs assessments, service specification and quality standard-setting stages in the commissioning process to improve the quality and efficiency of health services.
'Richard Lewis et al Devolved approach: commissioning outside England Having abandoned primary care-led commissioning altogether in 1997, Scotland is now trying to put primary care back in the driving seat.Community health partnerships (CHPs) are being set up from April 2005 as territorial organisations, each embracing the full range of NHS services and local authority social care.CHPs represent a renewed belief in collaborative planning rather than contestable markets.
In Wales, the purchaser-provider split has been retained, albeit with a strong emphasis on partnershipworking within local government and local communities and on reducing inequalities through a strong public health focus.
In Northern Ireland, fundholding and GP commissioning were eventually replaced in April 2002 with the creation of 15 local health and social care groups.LHSCGs were established to enable primary care professionals and local communities to play an effective role in the commissioning of services, including the management of a delegated budget for some services, while remaining sub-committees of their local health and social services board.
However, LHSCGs have struggled to secure GP involvement, and health service developments have been inhibited by continued political instability.
REFERENCE
1 The Health Foundation.A review of the effectiveness of primary care-led commissioning and its place in the UK NHS. www. health. org. uk
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