Health and Social Care Bill: GP Commissioning

Published on Tuesday, 28 February 2012 10:38
Written by Dr Judith Smith

When the NHS White Paper was published eighteen months ago it diagnosed three main ills: weak commissioning; insufficient competition and choice; and excessive micro-management from the political centre. This frustration with the performance of NHS commissioning precedes this Government however, particularly in relation to the seeming failure of the NHS to shift care from hospital to community settings, and reduce avoidable emergency admissions

Of all the solutions that the Health and Social Care Bill prescribes, GP-led commissioning is the most familiar - the English NHS having held faith with this policy, in varied forms, since 1991. In a recent paper published in the BMJ Professor Nicholas Mays (LSHTM) and I reviewed two decades’ worth of evidence on the attempts by various governments to enable GPs to commission care on behalf of local communities.

The logic behind the policy of GP commissioning is attractive:  GPs, by virtue of knowing their patients over a long period of time and though their familiarity with the ‘gatekeeper’ role, are well placed to purchase health services on behalf of the local population.
History has shown however that while GP commissioners start with a strong desire to be nimble clinically focused organisations, they are usually rushed by policy makers into becoming larger statutory bodies with wide-ranging responsibilities, and are then deemed bureaucratic and distant from local professionals.

Commissioning is hard to do, in whatever form. It requires sophisticated support to perform key tasks such as needs assessment, modelling future care demands, service specification, contracting and procurement, and outcomes measurement. However, the NHS currently faces a reduction in management costs of over 40%, making it likely that such support will be particularly hard to find.

Commissioning support arrangements are likely to have to be shared across a number of clinical commissioning groups, with different arrangements for services according to the level of financial risk. This will build on the existing spectrum of support arrangements developed for primary care trust and practice- based commissioning, and helps to mitigate the known diseconomies of scale inherent in devolved purchasing.

Clinical commissioning groups are designed to be fully fledged public bodies, and will need to be capable of withstanding judicial review of what may prove to be contentious decisions. Proposed amendments to the Health and Social Care Bill set out requirements for lay and specialist clinical involvement in governance. Putting these in place, and simultaneously engaging frontline clinicians in commissioning, will prove a big challenge.
All of this suggests that GP commissioners will, at least in the first few years, find it extremely difficult to move beyond the incremental development of community services to tackle the 'big ticket items' such as urgent care and the future configuration of hospitals. In order for CCGs to stand a reasonable chance of success, we recommend in our paper that there should be increased focus should on how GPs can also be made central to reshaping the provision of local health services, as well as commissioning.

One solution would be to take forward experiments with what has been termed a local clinical partnership or integrated care organisation—where the funder (a PCT cluster, or a separate group of commissioning GPs) allocates a population based budget to a group of GPs and other clinicians with which to deliver a range of services for local people. Such models would seem to have a better chance of bringing about significant changes to local health services, given what we know from the evidence about what works in primary care-led commissioning.

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