Experts call for larger PCTs and clinician led bodies to boost commissioning

BMJ 2010; 340 doi: (Published 30 March 2010) Cite this as: BMJ 2010;340:c1772
  1. Adrian O’Dowd
  1. 1London

    Commissioning in the NHS will start to work effectively only if radical changes are made that put clinicians far more in control of the process, say two new reports from health policy experts.

    Clinician led “integrated care organisations” and more powerful primary care trusts are needed to boost commissioning in the NHS, claim the two reports published on 30 March by the health policy think tanks the Nuffield Trust and the King’s Fund.

    Growing demand for care and a prolonged period of constrained budgets for the NHS mean that the way care is commissioned, organised, and delivered needs to change drastically, say the reports.

    The first report, Where Next for Commissioning in the English NHS, says that various problems currently exist with commissioning, such as the fact that primary care trusts have little control over the volume of referrals made by GPs and hospital doctors. Primary care trusts also have less autonomy than acute trusts.

    Another problem is that clinical leadership and engagement in primary care trusts is typically weaker than in provider counterparts, although practice based commissioning has gone some way towards addressing this.

    Importantly, capability and capacity for commissioning are key concerns for primary care trusts and practice based commissioning.

    The report says that the incentives for GPs to engage in practice based commissioning are weak and should be improved by granting real, risk adjusted, and capitated budgets to groups of GPs, in return for them assuming responsibility for financial risk and the health outcomes of the local population.

    It proposes stronger engagement by clinicians in local commissioning and suggests that, in time, primary care trusts may need to merge to secure greater management and analytic and clinical expertise and to have more purchasing clout.

    The second report, Where Next for Integrated Care Organisations in the English NHS, examines the potential for changes to the delivery of care through a new generation of clinically led organisations that both provide and commission care.

    The former health minister Ara Darzi’s next stage review of the NHS, published in 2008, outlined how these so called integrated care organisations could improve the coordination of care and led to a programme of 16 pilots, which are due to run until April 2011.

    The report says that although little evidence of their effectiveness is yet available, this form of integration could offer potential for improving the efficiency and effectiveness of care across various providers.

    If integrated care organisations are to become an effective force within the NHS, argues the report, major reform of the GP contract may be needed to embed new incentives for integrated care or to give primary care trusts greater discretion over the retention of GP contracts.

    Judith Smith, head of policy at the Nuffield Trust, said: “The NHS is at a fork in the road: it cannot hope to respond to rising demand and the severity of the financial challenge ahead by continuing to organise and deliver patient care in the same ways. We now need radical new approaches.”

    Anna Dixon, acting chief executive at the King’s Fund, said, “A combination of new models of care and much stronger commissioning that is outcome focused will be critical if the NHS is to meet future demand.”


    Cite this as: BMJ 2010;340:c1772


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