What will the white paper mean for GPs?BMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c3985 (Published 23 July 2010) Cite this as: BMJ 2010;341:c3985
The history of primary care led commissioning in the NHS is not encouraging. GPs took slowly to the introduction of fundholding in 1991. A few enthusiasts improved care for their patients, but overall, the effect was modest.1 Inequalities in care increased2 3 and GPs were not strategic in their purchasing decisions. The limited initial scope of fundholding was extended in 1995 under a scheme called “total purchasing”, but that model didn’t really get going before it was abolished by the incoming Labour government in 1998.4 Primary care trusts proved to be risk averse, bureaucratic, and ineffective commissioners, which led the government to revert to giving GPs notional budgets under “practice based commissioning” in 2004.5 The effects were again patchy, with GPs slow to get involved and with mixed levels of enthusiasm. By 2009, substantial numbers were engaged and starting to show some success in improving services.6 Despite that, practice based commissioning was described by the government’s own primary care tsar as “a corpse not fit for resuscitation”.7
And yet the idea persists that GPs hold the key to effective purchasing of high quality care. Now the incoming government plans to give them the biggest challenge of a generation—80% of the NHS budget will come under the control of GP practices. Critics of the scheme have been swift to emphasise the risks: GPs don’t want to hold budgets, they haven’t got the skills, they will need extensive management support, and multiple purchasers will cause contracting chaos especially in big cities. But is this all too gloomy? Has Andrew Lansley got it right? Is it possible that GP commissioning could transform the NHS? What would be needed for the new scheme to be a success?
The first need is for a sufficient number of GP leaders. Not all GPs have to be actively involved in commissioning, but substantial numbers do. Their motivation has to be to improve care for patients. The Royal College of General Practitioners sets out the values that define the profession—high quality technical care, personal care, continuity of care, and a commitment to individual patients that makes being a GP a profession rather than just a job.8 In the past few years, these values have sometimes been hard to find. In particular, GPs have redefined their roles in terms of technical quality of care and away from traditional definitions of whole person care.9 What we need now is a generation of GP leaders driven more by patient centred values and less by government targets.
These new GP leaders will not all be entrepreneurs and natural businessmen. So they will need strong management support, which may come from ex-managers of primary care trusts or from the private sector.10 What matters is that they have effective support to commission the care that they want for their patients. We are told that in many places, GPs don’t want to get together into commissioning groups. That is probably true, but what will inspire and energise them will be the emergence of leaders driven by a desire to improve care. We do not know the details of the new financial arrangements, but it will almost certainly be better if they do not allow GPs to make substantial personal profits from commissioning.
There will be major hurdles along the way. The formula that government decides to use to distribute budgets to GPs has the potential to cause major instability. An untested resource allocation formula (the Carr Hill formula) was introduced with the 2004 GP contract and had to be rapidly replaced as the sole basis for resource allocation because it produced large and unexpected changes to practice budgets. If the government pilots nothing else, it must pilot a range of resource allocation formulas before giving commissioning groups their budgets. Commissioning groups will also have to learn how to manage risk, either through arrangements that limit the cost to their budget of individual patients, or by insuring, or by pooling risk. They must make certain that patients with complex or expensive needs can register easily with a GP and receive the care they need.
As they develop into commissioning groups, GPs should generally form large geographically defined groupings. This will reduce the turmoil that multiple small purchasers are bound to create, it will allow them to be more effective commissioners, and it will help integration with community and local authority services. But they will need smaller subgroups for quality improvement and clinical audit to be effective. One size will not fit all the functions required of a commissioning group. GPs must also develop close relationships with hospital specialists and social care providers: purchasers and providers must work together to deliver the integrated care that their increasingly elderly populations need.11
Out of hours care will be a touchstone for the new arrangements. When GPs take on commissioning responsibility for out of hours care, they must not follow the example of primary care trusts and allow tired, poorly trained doctors flown in from Europe to care for their patients. There will be no primary care trusts to blame for poor care. It will be the GPs’ responsibility.
Government, for its part, will need the patience of Job. Major health service reforms cause years of pandemonium and it may take three or four years just to get back to where we are now.12 Research should inform changes along the way, but two full parliaments will be needed to know whether the experiment has been successful.
If Mr Lansley’s vision is right, and if GPs are guided by patient centred values when they provide and commission care for patients, then we will have a health service to be truly proud of. This is the challenge for general practice.
Cite this as: BMJ 2010;341:c3985
Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work, no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned, not externally peer reviewed