Plans by the coalition government to give GPs power and responsibility for holding real budgets and commissioning health services on behalf of their local communities have the potential to help improve care, but will need time and careful design if they are to be successful.
That is the verdict of six national organisations that have joined forces to inform the coalition government's aim of fully devolving commissioning power to GPs. They have published a new report that explores what needs to happen if GPs are to be given responsibility for leading commissioning in the NHS. The plans mark a difference from the existing model of practice-based commissioning as GPs would be handed real budgets and much greater autonomy, as well as responsibility. More details are expected in a White Paper, due in early July.
The report by the Nuffield Trust, National Association of Primary Care, NHS Alliance, NHS Confederation's PCT Network, Royal College of General Practitioners and The King's Fund outlines the opportunities this new policy direction presents. However, it warns that evidence from the UK and overseas suggests the policy will take time to develop and that there will be significant challenges in engaging more than an enthusiastic minority of GPs, reversing avoidable use of costly hospital care, and shifting resources into the community.
The six national organisations outline what they believe will be the most critical issues for the coalition government to address if the policy is to work. Their starting point is that policy-makers will quickly need to establish what it means for GPs to hold a real commissioning budget, work out the appropriate blend of risks and incentives that come with that budget, and acknowledge that a 'one size fits all' model of commissioning will not work. The report suggests that the key issues to be resolved include:
- Engaging GPs and specialist clinicians: given the known difficulties in securing high levels of engagement by GPs in practice-based commissioning, the new commissioning arrangements should be based on clinically-led and owned organisations in which clinicians can have a long-term and personal stake. It will be critical that specialist clinicians are engaged in these commissioning groups alongside GPs.
- Mandatory or voluntary: an important issue will be whether a minimum level of involvement by clinicians in certain aspects of commissioning should be mandatory or voluntary.
- Incentives and rewards: financial incentives and other rewards, such as greater autonomy and more attractive working conditions, should be transparent. They might entail GP groups retaining 100 per cent of any savings made through their commissioning activity, and being required to reinvest these in local services.
- Dealing with budget surpluses and deficits: clarity is needed on whether GPs and other clinicians holding budgets will have full autonomy and responsibility for determining how budget surpluses and deficits should be managed, including what happens if a GP group overspends or fails to meet health outcome or patient experience targets. A failure regime for GP commissioning will be needed.
- Management support: GPs and specialist clinicians will require high-level general and specialist management support from people who understand the nature of general practice, primary and acute care, and have sophisticated commissioning skills. GP leaders will also need to be supported and developed. This will be a particular challenge at a time when management costs, as well as training budgets, are being significantly reduced.
- Size and form, and accountability: determining an appropriate population size for GP commissioning groups and how a fair budget can be set, together with establishing the range of services to be included, will be vital. In addition, clarity will be needed over how budgets will be allocated to GP-led commissioning groups, who will hold them to account for the use of those budgets, and how their performance as commissioners will be assessed and managed.
Dr Judith Smith, Head of Policy at the Nuffield Trust, said:
'This policy is likely to be the centrepiece of the coalition government’s NHS reforms and has much potential to engage GPs in decisions about how local services are planned, help shift care out of hospitals, and reverse the upward trend in avoidable hospital admissions. But the scale of the challenge should not be underestimated – many previous reforms have struggled to win the support and engagement of GPs and this will again be a crucial issue, as will breaking down the Berlin wall between GPs and hospital specialists to get them to work closely together in managing budgets.'
NAPC Chief Executive Mike Ramsden said:
'NAPC strongly welcomes the coalition government's plans to devolve commissioning responsibility to primary care; we have campaigned long and hard for this change which we believe will lead to significant improvements in the delivery of better and more cost effective care for patients. But with responsibility should come accountability – and NAPC's manifesto sets out how we believe GPs and other primary care team members can be held accountable for their commissioning, as well as clinical, decisions. We will engage fully with the Department of Health to ensure that there is both effective implementation of this major change and full and proper support for GPs to enable them to take on this new role.'
Julie Wood, clinical commission federation director, NHS Alliance, said:
'This is a critical time for the NHS and which demands a radical change in how health care is designed and delivered. GPs leading the way, working closely with other clinicians and managers, is the right way to achieve better outcomes for patients whilst creating efficiencies. There is no 'one size fits all' solution and we need to work with clinicians to think through the risks, incentives and rewards to enable them to take this forward.'
David Stout, director of the NHS Confederation's PCT Network said:
'PCTs are already working closely with GPs to build the foundations for a new model of clinically-led commissioning and ensure the existing system manages future financial challenges effectively. The coalition government’s proposals present the opportunity to significantly change how commissioning is carried out, but will take time to implement. It is critical that PCTs maintain effective, high quality commissioning services over the next three to four years given this transitional period coincides with the biggest financial challenge the NHS has ever faced.'
Dr Anna Dixon, Director of Policy, The King's Fund, said:
'Giving GPs greater responsibility for how NHS budgets are spent has significant implications for the health care system. It is the right policy direction but will have to be very carefully implemented.'
RCGP Chairman Professor Steve Field said:
'I am proud to be a GP that works in an inner city practice delivering care to a deprived part of Birmingham. Like GPs across the country I work at the heart of my local community. GPs strive to deliver local services that are tailored to the needs of our patients.
'We don't just treat our patients when they are sick we also work hard to help them keep healthy. We work with patients in a holistic way. We strive to provide personalised care taking in to account their social, psychological and physical concerns, from cradle to grave. We don’t just work with our individual patients and their families; we also work with the population that we serve. Because of these individual and population approaches, I believe that we are best placed to commission health services for them.
'We already commission at the level of the individual patient, and by practices coming together as federations, we will be able to assess the health needs of the wider population, and then by careful planning secure the best quality of health services and health improvement services for that population within the available resources.
'We will need support. We will need to work closely with our specialist and management colleagues, but this report marks a new dawn. It puts GPs centre stage – right where we belong – in taking forward the NHS of the future. We are more than ready for the job.'
Notes to editors
1. For media enquiries please contact the Nuffield Trust press office on 020 7631 8455 or at firstname.lastname@example.org; the NHS Confederation press office on 02070743312 or at email@example.com; The King’s Fund press office on 020 7307 2585 or at firstname.lastname@example.org; the RCGP press office on 020 7344 3135 or at email@example.com; the NHS Alliance press office on 07951204999 or at firstname.lastname@example.org; and the NAPC on 020 7636 7228 or at email@example.com.