Increasing competition in NHS is hampering commissioning

BMJ 2011; 343 doi: (Published 22 September 2011) Cite this as: BMJ 2011;343:d6021
  1. Zosia Kmietowicz
  1. 1London

The government needs to rethink some of its key policies if England’s new clinical commissioning groups are to be better at providing integrated care than their primary care trust predecessors, a new report warns.

Pro-market policies with an emphasis on increased activity and more services, rather than collaboration and care in the community, have impeded the commissioning of integrated care, says the report from the health policy think tanks the Nuffield Trust and the King’s Fund.

It acknowledges that commissioning has the power to improve outcomes and reduce costs, but primary care trusts have struggled to introduce better services, especially for patients who need urgent care, patients with long term conditions, and people at the end of their lives, the authors concluded after conducting a national survey of English trusts and looking in detail at eight care pathways.

The process of assessing patients’ needs, drawing up contracts, and tendering for services is costly and time consuming, and trusts have often repeated work done in other parts of the country because of a lack of guidance and studies on what works. If the clinical commissioning groups are to succeed where primary care trusts failed, says the report, the government will need to provide them with much more support to help them adapt NHS payment, regulatory, and contracting rules to suit the needs of their patients.

It may even be necessary to reconsider the split between commissioners and providers and to allow commissioners to provide as well as buy services.

The report says, “One option would be to encourage GPs and specialists to take on capitated budgets and organise services to deliver defined outcomes. Eventually, patients might choose between the competing but clinically integrated networks that emerge.”

Judith Smith, head of policy at the Nuffield Trust and a coauthor of the report, said, “The drive to cut waiting times for planned care through competition has inadvertently put barriers in the way of developing services that would improve care for people living with complex, long term conditions and those who need intensive support at the end of their lives.

“If the new generation of clinical commissioners is to do better than their PCT [primary care trust] forbears, the government will need to craft an environment in which hospitals and GPs are encouraged to work collectively to shape new forms of high quality care for a particular population and face greater penalties for failing to do so.”

Chris Ham, chief executive at the King’s Fund and another coauthor of the report, said that three things needed to change to improve the clinical commissioning groups’ chances of success: better support from the national NHS Commissioning Board; promotion of both competition and integration by Monitor, the regulator; and the creation of the right incentives to support integrated care.

He added, “Payment by results was designed primarily to support choice and competition in relation to elective care at a time when the NHS budget was growing significantly. Alternative forms of payment are required to support integrated care—especially for people with chronic diseases and to support more coordinated unplanned care—when funding is very tight.”


Cite this as: BMJ 2011;343:d6021