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EDITORIALS: Chris Ham Reforms to NHS commissioning in England BMJ 2006; 333: 211-212 [Full text]

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Effective practice based commissioning – it will take more than incentives to GPs to make it work

Richard Ma   (1 August 2006)

The Power Of Hospital Providers

Jonathan R. Benger   (10 August 2006)

Effective practice based commissioning – it will take more than incentives to GPs to make it work 1 August 2006
Richard Ma, General Practitioner The Village Practice, London N7 7JJ Send response to journal: Re: Effective practice based commissioning – it will take more than incentives to GPs to make it work	Professor Chris Ham gives an interesting analysis of the progress of NHS commissioning reforms in England and states uncertainties about how it will work in practice, but he hasn’t asked all the necessary questions.(1) Currently, many service redesign and engineering initiatives have been based on demand management, such as encouraging self-care for minor ailments and use of GPs with specialist interests and specialist nurses, with the aim of reducing outpatient referrals and follow up appointments to save money or “free up resources”.(2) Despite many guidance on the process, there is ironic lack of patients in the so called “patient-led NHS”.(3) There is a real danger of patient involvement becoming a token step in the current NHS reform and the mantra of “choice” being a justification for the increased of the use of private sector. The same guidance also recommends PCTs support the PBC development by providing information on budgets, public health needs assessment and cost- effectiveness analysis of interventions. With the recent mergers of PCTs and strategic health authorities in England in the last 12 months, it is hard to imagine how public health departments can offer timely support for PBC with such reduced capacity and uncertainties about their future. The fact that maintaining financial balance is an urgent priority for all PCTs in England and the Department of Health means there is political pressure to re-engineer services quickly in order to demonstrate the efficiency of PBC. Inevitably, this will be at the expense of robust processes such as health needs assessments, where the often differing needs (felt needs, expressed needs and normative needs) are reconciled, and proper consultations with service users and stakeholders. Even with 100% participation from GPs, PBC will fail without public health and stakeholder involvement. References: 1 Ham C. Reforms to NHS commissioning in England. BMJ 2006; 333: 211- 2 2 Department of Health. Practice based commissioning: early wins and top tips. 2006. http://www.dh.gov.uk/assetRoot/04/13/13/97/04131397.pdf 3 Department of Health. Health reform in England: update and commissioning framework. 2006. http://www.dh.gov.uk/assetRoot/04/13/72/27/04137227.pdf Competing interests: Member of North Islington Locality Commissioning Group
The Power Of Hospital Providers 10 August 2006
Jonathan R. Benger, Consultant in Emergency Medicine United Bristol Healthcare Trust Send response to journal: Re: The Power Of Hospital Providers	In his editorial on NHS commissioning, Professor Ham states that "practices will have to collaborate with each other to change the behaviour of powerful hospital providers".[1] The concept of the over- powerful hospital provider appears to have gained credence in primary care, and also in central government policy.[2] However it would be helpful to be explicit about the behaviours that commissioners would wish to change. Hospitals are, on the whole, entirely reactive entities that respond to demand by providing healthcare. Given the role of primary care as a "gatekeeper" to secondary care in the UK, most of the patients being treated in hospitals have, in fact, been referred there from primary care. If too many people are being treated in hospitals then accessible alternatives, which are genuinely attractive to patients, must be provided. To blame hospitals for doing their job by responding to patient and primary care demand seems unfair. Professor Ham might do better to suggest that practice based commissioners will need to work hard to address healthcare demand and, where it is deemed necessary, create clinically effective and cost efficient alternatives to hospital treatment. References: 1. Ham C. Reforms to NHS commissioning in England. BMJ 2006;333:211- 2. 2. Department of Health. Our health, our care, our say: a new direction for community services. 2006: London, HMSO. Competing interests: I am employed by a hospital provider.