The principles of GP commissioning: general practices and the rationing dilemma

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Last week, the British Medical Association's GPs Committee published its 'fundamental principles' for the development of GP commissioning – its first position statement on the controversial flagship policy of the coalition government.

The development of a set of principles to underpin GP commissioning is clearly a very welcome move, particularly if it speaks to both GPs and patients. Over the years, commissioning has become an all-encompassing term for a highly complex activity, yet it remains vague and poorly understood. While world-class commissioning gave the term more meaning and energy – at least to managers – this approach now seems headed for the policy graveyard. Hence, a new set of principles is needed to clearly articulate what GP commissioning should mean to those that deliver and receive care.

The BMA's proposals provide a useful launch pad for the debate. These principles cover a number of areas, stating for example that the professionalism of GPs in providing the best care possible to patients should not be compromised (for example by inducements from commissioners that may adversely affect patient care), and that GP practices should receive adequate resources and support to play a full and active part in commissioning services.

The role of practices in GP commissioning is also set out, rightly emphasising the importance of working in partnership with other health and social care providers to co-design services and deal with the wider issues of public health and health inequalities. It is reaffirmed that any savings should be re-invested in patient care, that GPs should not personally profit, and that effective public and patient engagement is key. The NHS is also earmarked as 'the provider of choice'.

The BMA's principles, as one would expect, primarily address the concerns of its own membership and set out what GPs and general practice should and should not expect from working with GP commissioning.

Currently, many GPs feel ill-at-ease with GP commissioning since it implies that they – rather than a primary care trust – will be responsible for 'rationing' care. A core issue for the BMA, therefore, is the way in which it seeks to absolve GPs of direct responsibility for having to make hard cost-conscious decisions that might lead to a compromise on care provision.

Unfortunately, the reality of this role cannot be easily ducked. However unpalatable, a key principle of GP commissioning is that it brings together GP practices that spend public funds to work collectively as members of the commissioning body that makes and implements cost-conscious decisions.

The dilemma is that GP commissioning won't work effectively unless GPs and general practices can agree to follow these collective decisions, some of which will undoubtedly lead to much argument and tough decisions. It will be a difficult path to follow, but a necessary one. Thought should be given to how to manage, convey and implement such difficult decisions – a process that might require a new degree of openness to patient and public involvement.

As the consultation on the government's commissioning proposals moves forward, setting the principles for GP commissioning and the roles of its key partners will be important. However, they will also need to be more outward-looking; GP commissioning should be driven by the ambition to make sustained improvements in the health and well-being of all people in the communities they serve.

The challenge to GP practices, and to members of GP commissioning consortia, should be to strive to deliver and secure the highest quality of care for their patients within the financial resources that are made available to them.

This blog also appeared on the British Medical Journal website.


hank beerstecher

Comment date
12 October 2010
A ludicrous idea, giving the financial management of the NHS to subcontractors that provide primary care.

Sure, the quasi-GPs that see new jobs as big fish in a small pond will welcome the pending changes as another opportunity to avoid the coal face.

However, no new tools come with the job: The NHS is supposed to continue to provide universal care free at the point of use. If services cannot be moved from NHS care, if user charges cannot be introduced, if entitlements to care cannot be denied, the only thing left is to create waiting lists.

Waiting lists lead to a loss of efficiency and two-tear healthcare: Multiple attendances in primary care for the same problem, multiple referrals, increased administration, and more advanced illness means slower recovery, or obtain private care for those that can afford it.

More people want your goods than you can provide? Reduce demand or increase capacity. The more customers in the shop, the more you sell; the more patients in primary care, the more get referred.

On the demand side patients are trapped in the 'tragedy of the commons': even if the benefits are marginal it still pays to consume: there is an incentive to consume healthcare.

On the provision side GPs will be more profitable if patients did not attend, it frees up appointments and more patients can be taken on, which bring in more capitation. The only tool available in primary to reduce consumption is to restrict access and deliver lower quality care.

Capitation is probably better than fee-for service as it does not encourage supplier induced demand.
Capitation could promote efficiency: it is better to complete care in the shortest time possible, this frees up resources. The downside is it does not encourage quality. Quality would be influenced by true consumerism, customers weigh quality against expenditure.

So the only way to align incentives is to maintain capitation on the provider side, but weigh this by quality, and introduce user charges to reduce demand on the consumer side.

What we are likely to see though is more of the same merry-go-round, where more and more of low value (unnecessary) care is delegated to staff with low qualifications and access/qualiy are compromised to manage demand.

Steve G

Comment date
08 September 2010
Sorry but this one step forward is in fact a giant leap backwards.

We have had a similar initiative before and it led to huge uncertainties in the Trusts.

If the GPs buy it they will end up the fall guys when it all goes wrong, which it will.
I would also predict at least one Trust failing as contracts move to the private sector.

Sukhdev Singh

GP and PEC Chair,
South Birmingham PCT
Comment date
06 September 2010
It is clear that this policy has been identified by many as controversial and high risk. I cannot see anyone offering a better solution to getting the NHS out of its mess, during an unprecedented financial credit crunch. The trick is to support GP's in taking this policy seriously and to start changing culturally so that we, as GP's, are not just the patient's best advocate, but also their best advocate for their share of resources in the wider NHS. The GPC principles paper is very welcome, as it asserts the values that should drive GP's, whilst also pointing out bluntly the likely traps that we should be weary of. They did not do this with GP fundholding. The RCGP is also supportive of this new policy. With all this strategic clinical alignment, getting operational alignment is the next, but bigger task. I would value other national organisations, such as King's Fund, to clearly state what they feel are the main principles to support delivery by GP commissioners.

Nick Goodwin

Senior Fellow,
The King's Fund
Comment date
29 August 2010
Hi Bob,

Indeed so.

When weighing-up patients' medical needs against monetary costs the answer has to be to try and address inefficiencies in the system throiugh re-design rather than stint on care. However, until the NHS as a system understands how to get a handle on the inflationary forces in the system (e.g. rising patient expectations, number of older older people, LTCs, mental health, unhealthy lifestyles, payment by activity etc) we cannot really expect GPs to try and save the system money. My feeling is that it's a good thing to align providers (not just GPs) and commissioners, but if this is perceived as a largely political agenda that might endanger the patient-centered ethic central to general practice then it's unlikely to get too far.

Bob Hudson

Comment date
27 August 2010
Hi Nick. Yes agree with this. Fascinating policy situation unravelling. Lansley seems to think he can win by divide and rule - set the GPs against the consultants. Can't see this working. Politicians v Medics down the decades has only ever produced one result - victory for the medics!

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