Practice based commissioning: what future?BMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b4543 (Published 11 November 2009) Cite this as: BMJ 2009;339:b4543
Mark Pownall asks whether the government’s flagship policy for improving quality and saving money has any future
Practice based commissioning was last month characterised as “a corpse not for resuscitating” by the English national clinical director for primary care and former pro-fundholding firebrand, Dr David Colin-Thomé. An ailing patient, certainly, commentators agree, but most of them believe that survival is the most likely outcome, although probably after some radical surgery.
It’s a confusing time for an idea that has had a large amount of political capital invested in it. As recently as September, health secretary Andy Burnham declared that practice based commissioning “needed more oompf.” In March, sensing a drift of attention from commissioning work by primary care trusts (PCT), the Department of Health issued a “vision” for practice based commissioning designed to shore up the policy. But it does not seem to have had the intended effect.
“That vision document has not made a difference that I have seen,” says Dr David Jenner, the practice based commissioning lead of the NHS Alliance and a general practitioner (GP) in Devon. Perhaps, he acknowledges, there may be a shift when practice based commissioning comes to be “marked” on PCT scorecards as a measure of quality, but by that time the general election will be looming.
Can the Department of Health press on wholeheartedly with the same form of an initiative that more than three years since its inception is delivering only patchy results, and knowing that a change in government—and emphasis—is likely by next May? Can either GPs or PCTs muster up some enthusiasm and overcome their respective fears of a thankless administrative burden and a loss of financial control of service provision?
“There have been lots of fine words, but there is huge variation in both commitment and achievement by PCTs and strategic health authorities,” says Dr Jenner. “When they keep GPs and PCT commissioners out, as many do, they cannot achieve much. A lot of GPs are frustrated; they’re all dressed up with nowhere to go. They’ve set up companies and consortia, but there has been small scale achievement rather than large scale system re-design, which was the idea.”
Natasha Curry from the health think tank the King’s Fund, which has carried out research on practice based commissioning, says that although it has not gathered enough momentum, practice based commissioning will not be killed off in the foreseeable future. “Has practice based commissioning gone off the boil? I am not sure it was ever on the boil,” she says. “There is a small group of GPs who are enthusiastic, the type of GPs who were enthusiastic about fundholding. But it’s a very small group.
“But I don’t think this is a policy that is going to be abandoned. The department has begun to try to get things moving again, and it has stressed that practice based commissioning remains a priority for PCTs and it is not going to go away, so they have to do something about it. There is some evidence of small and local progress by a small number of PCTs.”
Dr Jenner says practice based commissioning has failed to tap into the entrepreneurial spirit of GPs as fundholding and previous iterations of fundholding did, and practice based commissioning does not have the same mass appeal. “There is a small minority of enthusiasts for practice based commissioning among GPs, and then a majority that is happy to go along with it,” Jenner adds.
In theory, everyone wants practice based commissioning to succeed: GPs shape the services for their patients according to local health needs, leading to more flexible, agile services that are more responsive, less monolithic, and more efficient because they are driven by need, not by the services that the supplier (largely hospitals) wants to offer.
“The whole case for local commissioning—working in partnership with the community and other stakeholders to try to produce and commission high quality patient experience and deliver robust value for money—makes perfect sense,” says Dr Jonny Marshall of the National Association of Primary Care. “You cannot achieve a locally responsive health service by trying to run it centrally; that will not work. But it is not so much the policy that is the problem, more its implementation: both PCTs and GPs have failed to unlock the potential.”
Not allowed to work
For Dr Jonathan Shapiro, from the department of public health and epidemiology at the University of Birmingham, there are just too many entrenched interests for practice based commissioning to overcome, from the party political and the economic to threats to bureaucratic power bases.
“Practice based commissioning hasn’t worked because it hasn’t been allowed to work,” he says. “A Labour government hasn’t wanted to be seen to recreate [the previous Conservative government’s policy of] fundholding, and ministers who were keen genuinely to ‘let go’ the reins of power, such as [Alan] Milburn and [Patricia] Hewitt couldn’t do so because of more left wing backbench opposition.”
Just as damaging as the internal Labour politics, says Dr Shapiro, has been the reluctance by the powerful bureaucracies within PCTs to relinquish management (and financial control).
He comments: “PCTs haven’t wanted to let go because they have been obliged to keep responsibility for the outcome, and felt they didn’t have the levers to control it.”
For Dr Marshall, it is more a matter of profound cultural misunderstandings: “general practices have a history of being independent and not working together whereas PCTs are reluctant to devolve responsibility to practices.” “GPs are from Mars and PCTs are from Venus,” is how he describes the situation. “It’s a lot to do with the different cultures in the NHS. Practice based commissioning is much more about partnerships and relationships than either group has been used to.”
Conflict of interest
Dr Shapiro says GPs have seen little possible benefit for the time that would need to be spent to make full practice based commissioning a reality. “GPs have seen very little incentive to take it on, in terms of power, influence, money or anything else. It just felt like a watered down sop.”
In part he blames an “English puritanism” about rewarding GPs who achieve more efficient health services through commissioning. Because there have been huge concerns about conflicts of interests of those commissioning services, business plans that include financial incentives for good performance have had to go through tortuous approval processes that have taken months, even years.
“GPs put in business cases that are supposed to take six to eight weeks to be processed, but PCTs are sitting on them for a year or more because they are paralysed by fears about risk,” comments Natasha Curry.
According to David Jenner, the result is that all but the keenest enthusiasts have given up on commissioning “and gone back to their day jobs” of running a general practice and treating patients.
It’s an analysis supported by research from the King’s Fund and the NHS Alliance, who surveyed GP practices and commissioners earlier this year. The two main barriers to progress identified in the survey were a lack of time and “PCT issues” that included slow pace, risk aversion, instability, and disinterest. Excessive bureaucracy, poor relationships, and unavailable and poor quality data were also seen as obstacles.
What would an incoming Conservative government do about practice based commissioning? Shadow health secretary Andrew Lansley sketched out the bones of a policy at the party’s annual conference in Manchester, where he said GPs would be put in charge of budgets for their patients’ care and would be responsible for diagnosis, referral, and NHS treatment, using a “real” budget to pay for it. To avoid conflicts of interest, GPs are unlikely to be able to commission themselves, and would not be able to profit excessively if they made savings from efficient commissioning. If this policy makes it through into government, it will echo the fundholding scheme from the early 1990s.
“It looks like compulsory total fundholding to me,” Dr Jenner comments. And he points out some potential complexities to the scheme: “if the GP practices become accountable for the budget, and that is built into the contract, will they as a partnership with unlimited liability go bust if they overspend on services?
“The details are important because what we are seeing at the moment are statements of intent, but no detail about how it might work,” he says. “Will compulsory commissioning work in an area where only a minority of GPs are interested? If you make people legally accountable for the budget, how do you avoid them undertreating when under financial pressure, especially when outside organisations like NICE [the National Institute for Health and Clinical Excellence] are making external demands on your budget?”
Dr Marshall says there is a balance to be struck with any introduction of “real budgets” and a system of carrots and sticks. “There has to be pain when something goes wrong, but there have to be limits to that pain or no practice will want to take the risk. A little bit of pain, so if you don’t deliver there is a penalty, but there has to be a proportional amount of gain to make the effort of commissioning worthwhile.”
But whatever the flavour of the next government, with a more or less market centred ideology, some form of commissioning will remain. If, as now seems unlikely, Labour win another term, practice based commissioning may move towards a system involving integrated care organisations. If the Conservatives win, there will be a more market oriented system, perhaps support by private sector companies. The corpse walks.
But it needs to revive itself, says Dr Marshall. “If we are going to take £15 billion of resources out of the NHS and still deliver quality services, we will need some form of practice based commissioning because GPs understand their patient needs and provide clinical leadership, and PCTs can provide that strategic approach and data analysis. But we’ve both got to up our game.”
Competing interests: None declared.