PBC is desirable but sadly not workable as a universal mechanism. It wasn't in the 1990s, and it isn't now

Practice-based commissioning: the triumph of hope over experience?

Ten years ago this week, the 1997 general election was partly fought over whether GPs should be fundholders. With hindsight, it may seem odd that such an arcane aspect of NHS architecture was invested with such ideological salience.

But at the time fundholding divided the political parties and split the medical profession down the middle. Half of GPs were animated in its defence; the other refusenik half wanted it 'fixed' - in the way that a vet 'fixes' a randy tomcat.

For an incoming Labour government committed to 'abolishing the internal market while keeping the purchaser-provider split', it was GP fundholding that went. The British Medical Association and royal colleges were duly grateful.

With hindsight I think we threw out the baby with the bathwater. The hope was that entrepreneurial ex-GP fundholders would sustain their energy inside the new primary care groups, so their efforts benefited all.

But rather than a rising tide lifting all boats, many of the most innovative GPs simply gave up. Budgets were replaced by committees. The effort-reward ratio worsened. And this most transactional group of health professionals spotted the fact that there was more money to be made in personal medical services than in commissioning, and off they went.

But wind the clock forward 10 years, and we may now be in danger of making the exact opposite mistake: to invest the idea of GP practice-based commissioning with almost magical powers, representing the answer to the NHS's manifold weaknesses in commissioning.

For now we find both government and opposition, as well as both the National Association of Primary Care and the NHS Alliance (once bitter enemies), all arguing that if only we had practice-based commissioning on an industrial scale, our prayers would be answered.

Yet the inconvenient truth (as Al Gore might put it) is that practice-based commissioning is desirable but sadly not workable as a universal commissioning mechanism. It wasn't in the 1990s, and it isn't now.

Why? For starters there is now greater appreciation of the fact that someone - other than GPs - needs to proactively commission primary care itself. There are also key economies of scale in the specialist techniques needed to move commissioning beyond generalised blather, so the science-to-art ratio improves dramatically. And perhaps most importantly, the unavoidable reality is one of widely varying GP capability and motivation.

As I argued in my column last month: optimistically assume perhaps half of all GPs could be seriously interested in commissioning activities. And optimistically assume perhaps two-thirds of all GPs could be competent commissioners. The combined probability is therefore that only a third of GPs will be both willing and able to make practice-based commissioning deliver in the way that its advocates suggest.

All of these factors were true last time round too, which is why even after six years of crossing GPs' palms with silver, by 1997 still only half of them were in fundholding, and on aggregate fundholders controlled only 15 per cent of the NHS budget.

What's more, in two important ways the prospects are actually worse this time round. First, the expected pay-off to an individual GP from assuming commissioning responsibilities is lower under practice-based commissioning than it was under fundholding. That's because by reducing the financial distortions of key aspects of fundholding, the new scheme has correspondingly weaker opportunities for personal financial gain. Second, the opportunity cost to an entrepreneurial GP of spending time on commissioning has shot up.

There is now far more money to be made by the income-maximizing practice in sweating the quality and outcomes framework, in taking over neighbouring practices in sweetheart deals with the PCT, or in providing intermediate care services mostly immune from the chill winds of transparent competition that hospitals are beginning to face.

So here is the double whammy. In those urban parts of the country where the quality of primary care is highly variable, the prospects for widespread competent GP commissioning are decidedly mixed.

But in better-off parts of the country where the quality of general practice is typically high, their earnings from alternative sources have sky-rocketed, meaning the price of inducing GPs to commission may now exceed the theoretical value of having them do so.

Indeed the most pessimistic among us go further and point out worrying signs that in the rush to embed GP-led commissioning, in places GPs are merely using it as an opportunity to form local cartels capable of channelling taxpayers' cash to their own, for-profit practices through the supply of substitute secondary care or diagnostic services - entirely immune from normal procurement rules or fair and transparent competition.

At this point let me repeat: GP engagement in commissioning is highly desirable to support clinically meaningful pathway redesign, help manage scarce clinical resources, and lead needed change in service configuration. So I believe we should strive wholeheartedly to support GPs in these tasks.

But there is no contradiction in expressing strong support for the idea of practice-based commissioning while taking a long cool look at its arguably low likelihood of success over the coming years as the main driver of commissioning in large parts of the country.

Wikipedia lists over 50 different types of cognitive bias. In the debate on practice-based commissioning, it is perhaps the most prevalent bias of all that we've got to watch out for: wishful thinking. -

Simon Stevens is chair of UnitedHealth Europe and visiting professor at the London School of Economics. Simon_L_Stevens@uhc.com