GP led commissioning: time for a cool appraisalBMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e980 (Published 16 February 2012) Cite this as: BMJ 2012;344:e980
All rapid responses
As our paper made clear, evidence points to the importance of sufficient and high quality management support for CCGs. However in writing a short article, choices had to be made about what aspects could be discussed meaningfully. FESC was not taken up by PCTs to any significant extent under the last government (ref 1), and it remains to be seen whether CCGs will act differently.
The biggest determinant of private sector involvement in commissioning support (which it should be emphasised is a separate matter from the 'privatisation' of either finance or provision) is likely to be the fees on offer for CCG support. Predictions about the market are difficult however when the Government has not yet signalled how much CCGs will be allowed to spend on management support.
The Department of Health's recent publication, Towards Service Excellence does little to clear up the uncertainties. While it restates the commitment to a diverse range of support providers, it also implies a strong preference for a national system of support, at least initially (ref 2)
Dr Moylett is probably right to predict that some CCGs will buy in commissioning support from the private sector. However it does not follow that these organisations will have 'major control of the NHS budget'. Indeed, our understanding, based on repeated written assurances by the Government, is that the Health and Social Care Bill forbids clinical commissioning groups from either sub-contracting or delegating their commissioning decisions to other organisations (Ref 3).
Ultimately, CCGs as statutory bodies will be responsible and accountable for their commissioning decisions, irrespective of whether their management support comes from the private, voluntary or NHS sectors.
Ref (1) Naylor C and Goodwin G (2010) Building high quality commissioning: what role can external organisations play? King's Fund
Ref (2) NHS Commissioning Board (2012) Developing commissioning support: Towards service excellence
Ref (3): HL Deb, 16 January 2012, c117W
Competing interests: No competing interests
Judith Smith and Nicholas Mays’ article made interesting reading in the above article in BMJ, but there are a number of points to be made to set the record straight in relation to what they term ‘GP led commissioning’, now known as clinically led commissioning.
The Health and Social Care Bill for the first time in the history of the NHS will bestow upon Clinical Commissioning Groups, comprising individual clinicians, financial responsibility for the commissioning of healthcare. This means, very importantly, that both clinical and financial accountability will, again for the first time, be aligned in statute and clinicians will be required to consider the appropriateness of every clinical decision they now make. The alignment brings with it many advantages, including the opportunity to manage unwarranted variability in care, as well as eliminate ineffective, and sometimes dangerous, clinical practices. The NHS has hitherto no experience in its history of GPs have statutory financial accountability and to compare implicitly the proposed reform with GP Fundholding scheme, where practices were no more than subcommittees of the then statutory health bodies, which operated on a practice basis and extended only to community services and elective surgery, is to compare chalk and cheese.
Total purchasing, however, in the 1990s gave us a glimpse, but only a glimpse of the art of the possible, with groups of practices coming together on a voluntary basis to modernise care locally across care pathways in partnerships with secondary care clinicians. I would argue, however, that the new statutory responsibilities enhance the scope for clinical commissioning groups to transform and modernise healthcare comprehensively for the first time in the NHS’ history.
That commissioning is now a complex, sophisticated business, is unarguable. That even the most innovative, skilled and enthusiastic clinicians think they will be able to discharge the new commissioning function without extensive support is to fail to understand both the clinical commissioning agenda and clinical commissioning leaders. GP leaders both locally and nationally are under no illusion about the implications of this aspect of the reforms. It is for this very reason, that primary care clinicians have been so exercised about the choice of commissioning support.
The article also disregards the vast array of authorisation processes being set in place, as I write, to ensure that Clinical Commissioning Groups operate as corporate, statutory bodies, with governance arrangements, overseen by an army of lawyers, firmly in place, to ensure transparency and accountability, as well, importantly, as the engagement of stakeholder practices, their patients and populations.
The proposed rethink fails to embrace the details of the clinical commissioning reforms, examines ‘research’ evidence partially, and impractically makes suggestions without any assessment of the outcomes of current legislation.
The NHS will not survive to deliver comprehensive healthcare for its population without a radical reform that only clinicians, both those in primary and secondary care, deliver through the Health and Social Care Bill.
Competing interests: No competing interests
Why no mention of involvement of the private sector?
Judith Smith and Nicholas Mays have written a clear analysis of GP led commissioning including the major problems that this entails(1).
However they managed to discuss the whole subject without once speaking about the involvement of the private sector. Why so coy?
The crucial point that they raised is that there is a "need to invest heavily in management support if devolved commissioning in the NHS is to succeed. However, the NHS currently faces a reduction in management costs of over 40% making it likely that such support will be hard to find." (1)
Where will this “support” be found? I am sure that Smith and Mays will be well aware that many consortia will subcontract their activities to health insurance companies but there was no mention of this at all.(2)
They will be aware of the Framework for Procuring External Support for Commissioners (FESC) set up in 2007 by the last Labour government. The FESC was designed by the Department of Health in collaboration with McKinsey. In 2007 14 companies, most of them major US and UK health insurers (e.g. BUPA, UnitedHealth Europe, McKinsey) were selected to assist PCTs in this FESC. The FESC was already in place before Lansley proposed transferring commissioning to GP consortia. By mid-2010 many PCTs were working closely with FESC insurers and in December 2010 UnitedHealth signed a contract with a new pathfinder consortia in Hounslow to handle all referrals from February 2011.(3)
It is expected by many that GP led commissioning groups will be using private health care companies to help them commission services. These private companies will have major control of the NHS budget via this commissioning function.
I am left wondering as to why Smith and Mays did not think it relevant to include these facts in their analysis of GP commissioning. Why so coy? Are Smith and Mays being protective of the government and their mantra of “no privatisation” or are they not wanting to frighten BMJ readers, and the public, with the spectre of privatisation of the NHS?
(1) Smith J, Mays N. GP led commissioning : Time for a cool appraisal. BMJ 2012;344:e980.(25 February.)
(2) Reynolds L, McKee M. GP commissioning and the NHS reforms: What lies behind the hard sell? J R Soc Med 2012;105:7-10
(3) Leys C, Player S. The Plot Against the NHS. Merlin Press 2011
Competing interests: No competing interests
Many innocent years ago I was Chair and clinical lead of one of the first 4 national GP total purchasing pilots (Worth Valley Health Consortium). The consortium covered a discreet geographical area well served by an excellent district general hospital. As our experience in commissioning increased, long before any research was published into our progress, we realised that the budget boundaries between primary and secondary care were impeding any overall progress in improving efficiencies and outcomes for our local population.
Accordingly, approximately 15 years, ago my general manager and I approached the Department of Health offering a pilot horizontal integration of budgets across ourselves and our local secondary care provider. We saw this as the next logical step (and though we also had the grandiose idea of adding integration with social care we knew that was a step too far). We were gently told that our offer 'was not the direction of travel at the time'. If only the risk had been taken and we had been given the opportunity the NHS might be in a completely different place today!
Competing interests: none (though I am vice chair of NICE I do not believe it is relevant or a conflict)