Breaking the mould: learning new ways to commission health care

Commissioning is starting to swell the column inches of the GP press. A recent PULSE survey of pathfinder commissioners demonstrated significant interest in using the private sector for support, with nearly a third of responding consortia saying they intended to enlist external agencies to support referral management.

We can claim then, that the private sector's involvement will not be limited to non-clinical areas. So what are we to make of this, and is there any way to counter the disapproving reaction to the name that we dare only whisper... 'the private sector'?

It is so difficult at times to cut through the absolutely polarised views that the worlds of public and private engender. I've seen good, bad and indifferent from both sectors – so how do we break out of the mindsets that constrain us? This for me is one of the biggest challenges in setting up GP consortia.

Primary care trusts have been excellent at commissioning some services, average at many and sadly poor at a few – this is usually due to a host of systemic reasons and not necessarily a reflection on the staff. Don Berwick, the Chief Administrator for Medicare in the USA, tells us that if we carry on with the same processes we will get the same results; can we afford to take that risk? I think that we can't afford not to change. The whole premise of these reforms is that they put patients and clinicians in the driving seat, so we'd be daft to send them on their journey with their hands tied.

First, we must begin to differentiate those functions that have worked well from those that haven't. We need to focus on the functions rather than the 'bad' private vs 'good' public argument. Let's look at these areas through a new lens.

I recently met with MS Society and Parkinson's UK who have come together to develop a commissioning group. The work they have done is like a breath of fresh air – these groups have so much to teach consortia. For as well as liberating the NHS, we need to liberate the third sector, which has the creativity and ability to truly make a difference. When we focus on the private sector we must look more widely and consider who is best placed to deliver first-class commissioning support. We must also lift our sights above current geographical boundaries, as many of these functions will be most cost effective at scale.

This brings us on to small versus large consortia. For me, small is beautiful: smaller consortia tend to have well-defined clinical relationships and networks that are able to deliver the most change and innovation on the ground. But surely we can have the best of both worlds, with smaller groups forming one consortium with localities or alliances? The support services could sit over these groups, hosted by one or other consortium, helping us to break away from the notion that all support services are provided to just one area.

The duties and responsibilities of consortia are becoming clearer, and soon they will be able to look closely at all the functions they need to support them. I would argue that some functions, including referral management, can only be done by the members of the organisation: you cannot delegate functions that reflect your behaviour as an organisation. However, other functions can be done from afar and by many different providers. Let us get the debate back to who is best placed to deliver these necessary functions.

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Comments

#363 Nigel Starey
portfolio GP

Good stuff Paul - but we need to realise that if consortia are to improve clinical efficiency they need to address mindset issues among their members and their partners.As you say, others such as in the private and third sectors have to be involved - because they are not constrained by history and can help us look at things differently

#364 Bernard Stacey
Consultant Physician

Is it optimism or naivity that surrounds thiese new 'reforms'? Miles of paper and countless kilobytes are being filled with pontificiation by healthcare's chattering classes but the idea that the Bill is more a rebranding than a reform has not yet percolated through.
GPCCs are PCTs in all but name. A few general practitioners with administrative aspirations may sit on the boards but the work of commissioning the same services will be done by the same ex-PCT employees as soon as they have finished counting their severance pay for they will be the only ones who can negotiate the clumsy, red-tape heavy processes that will sadly endure.
As long as the falicy of an internal market endures - trying to apply free market principles within a closed market environment, further constrained by non-business considerations unique to healthcare - then no real change will occur.
The division between primary and secondary care is entirely artificial from the patient's point of view and yet the latter is almost wholly disenfranchised from enabling methods of care, even though that is where a huge amount of the knowledge resides.
This is not a 'new way to commission healthcare' at all: merely some tinkering on the edges of a failed system.

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