Should the NHS abolish the purchaser-provider split?BMJ 2016; 354 doi: https://doi.org/10.1136/bmj.i3825 (Published 12 July 2016) Cite this as: BMJ 2016;354:i3825
All rapid responses
Does the appointment of a preacher as the chairman of a bank ring a bell?
Doctors have been expected to be high level business managers in the purchaser provider scheme, the internal market scheme, budget holding schemes and more recently in the clinical commissioning process with expectations of being able to handle a large budget effectively. This is not the only time that doctors have been expected to function outside their range of expertise. In the mid to late seventies David Nicholson declared that “Within two years we want a doctor applying for every chief executive post advertised” and again “Where clinicians and managers work together, there is almost nothing you can’t achieve”.(1) But what he expects goes way beyond cooperation. It even has more the tone of a takeover.
Let alone the intentions behind these schemes, the common fallacy in all this and in the arguments presented for yes or no surprisingly is the failure to recognise one simple fact that there is no provision to ensure that those expected to undertake financial and administrative duties should be competent and have the necessary expertise to perform these duties. Where in the routine training of a doctor is this catered for?
Members of the medical profession and the administrators should have mutual respect for each other’s abilities. Trivialising management with an ‘anything you can do I can do better’ attitude is a recipe for disaster.
As Maynard a leading expert in health economics based on his experience as chair of a provider Trust and a CCG has pointed out ‘commissioning is a complex task’ and is made even more complex by the lack of adequate information. He has however been polite enough not to question the ability of doctors to undertake this task.
Both Maynard and Dixon provide another reason why the Clinical Commissioning Groups (CGCs) was not successful. Maynard highlights the vast sums of money required to make the scheme a success and Dixon points out that ‘CGCs were born as the money ran out and their effectiveness was restricted’. Two vital requirements expertise to run the scheme and finances essential to make it a success was lacking. This did not hold back these aims. The concept of CGC and the aim to have doctors as chief executives in large numbers was aimed to satisfy ideologies.
It is the duty of the government and the NHS administrators to encourage doctors to undergo the necessary training to undertake financial and management duties. We have in recent times seen the trend of doctors following courses in finance and administration. This could be reflected in the selection of medical students. It could be an intercalated degree.
Doctors clearly have had more sense and recognising their own limitations have not set off to become chief executives. But it is a matter of concern that some involved in the commissioning process have not shown similar restraint.
(1)The rise of the doctor-manager BMJ 4 August 2007 Volume 335
Competing interests: No competing interests
Many of Maynard's criticisms of commissioning in the English NHS are correct. But there are two reasons why that doesn't imply we should abolish it.
First: are there any benefits? The evidence for the effectiveness of provider competition (a major theoretical justification for commissioning) exists, but is weak. Though this is perhaps unsurprising given the way commissioning has been designed. So Maynard is right to say the experiment doesn't look like a great success.
But the first compelling reason why this doesn't imply the need for another major reorganisation is that such a reorganisation would certainly incur significant costs and disruption. But the benefits of abolition (like the benefits of provider competition) are uncertain. Anti-market campaigners have often quoted very large numbers for the potential savings of abolishing the internal market but these are implausible and not apparent in other places that have reverted to the older structures. Plausible estimates of savings, if they exist at all, are very unlikely to compensate the NHS for another few years of systemic disruption.
But one of the reasons why the savings from abolishing the market are likely to be small is also one of the reasons why the system doesn't work well now. Maynard correctly identifies that good commissioning decisions require good information. But the system is fragmented and much of the information is not accessible. I would add that the system has been starved of the management capacity to process that information (the NHS is undermanaged by any reasonable benchmark and when it comes to information the system exists on starvation levels of capability and capacity). It is little wonder that CCGs can't make better decisions: they mostly lack either the information or the capacity to make sense of it. abolishing them wouldn't help, though. Someone still has to make planning decisions and allocate the resources to the most useful ends. And abolishing the purchaser provider split would not magically create more capacity to make good decisions. So we would get more disruption but no tangible benefit.
A better approach would be to acknowledge why experiments like commissioning have not worked well. It's about information. If we are going to do a better job of decisions in the NHS (however we choose to organise the system) we need good reliable information about what is going on and what the outcomes of treatment are. The current NHS is woefully deficient in good information: it isn't organised to collect it effectively; it lacks the capacity to process it quickly; and it is starved of the capability and capacity to derive useful insights from the information it has. Information skills are pushed down the priority list every time a politician says "more resources to the front line" despite the fact that we won't allocate those resources to the right parts of the front line if we don't have good information about where they are needed.
However the NHS is organised, it can't do a better job without good information. We'd be far better investing a little in that before we tear up the structure again.
Competing interests: No competing interests
My peers and I have been directly prevented from maximising our professional contribution to the nation by the internal market. Claims that benefits arose from it are highly suspect. Certainly some amongst us profited hugely, many were exploited, many scores of millions of professional man-hours were squandered in meetings and over paperwork, resources were diverted from patients to managerialist flummery, treatment was denied or delayed and the nature and purpose of healthcare was corrupted.
Healthcare, properly delivered, is not nor can it ever be a commercial undertaking - neither as a faux-market nor as a neoliberal free market phenomenon. Its sole purpose is, or should be, the delivery of optimal healthcare. When rationing is required, and it always will be, then that must be a wholly and explicitly political decision that is clearly set before the electorate at election time.
The mechanism by which commerce was stabbed into the body of healthcare has been as destructive as the faux-market itself. Commercial/industrial management techniques are anathema where the 'feed-stock' consists of billions of unique and constantly varying individuals with capricious minds, bodies and disorders, the 'product' consists of billions of unique entities - often never fully finished, the workforce itself is the major part of the 'process' and the outcomes are so diverse and protean as to defy categorisation.
Contrary to Dixon's opening sally, historically practitioners of all disciplines were answerable to the patients first. The advent of the purchaser provider split, fundholding, commissioning and all the associated witless fandangos has only achieved spectacular wastes of opportunities to help patients, money, time and professional lives. It has been an unequivocal disaster.
Reformation of the NHS has to be a continuous process. There is no final destination because the nature of the changes that will be encountered are not yet known. However, some basic premises can be essayed:
Patients first - always and everywhere.
Rent seekers and politicians to be statutorily banned from influencing healthcare policy.
Professionals of all disciplines to be permitted to optimise their clinical practice without non-clinical distractions.
Develop the habits of direct professional co-operation and autonomy.
24/7 professional assessment and advice available to all, everywhere, free of charge.
Limits to NHS coverage agreed - stop covering the costs of treating minor and self limiting problems inter alia, employ Pigouvian taxation to provide additional NHS funds and, eventually, to reduce demand.
Institute cost effective and very slim administration in place of costly and bloated 'management'.
Consider departmental/practice PBR such that continuous improvement is rewarded, rather than targets achieved. The measures to be broad and department specific - thus everyone shares the jeopardy, from cleaner to consultant.
Where diagnostic protocols are complex, rapidly changing or numerous, for example malignancy, dedicated secondary care facilities be established to which those with suspicious symptoms or signs can be referred same-day for immediate triage, investigation and onward referral to the relevant specialty.
...and so much more.
Patients cast into the maelstrom of the private sector are very vulnerable. Is the treatment being offered that which is optimal for them or simply that which the company is prepared to provide? How can a patient tell? Who is scrutinising what is going on?
'Savings' in healthcare are actually a measure of treatment denied and profits likewise.
Competing interests: No competing interests