Memorandum by Dr Pauline Brimblecombe
(COM 116)
COMMISSIONING
"World-Class Commissioning": what does
this initiative tell us about how effective commissioning by PCTs
is?
The vision of World Class Commissioning is for
the available resources to be used as effectively and fairly as
possible to promote health, reduce health inequalities and deliver
the best and safest possible healthcare. Prior to the WCC initiative
PCTs delivered services on a historical basis rather than a public
health needs assessment. Delivering on demand rather than need
has produced wide variations and contributed to some of the health
inequalities. The fact that PCTs have not fulfilled their commissioning
role to date is unsurprising given the emphasis of the health
reforms on the provision side and on "patient choice".
Despite the emphasis of WCC on priority setting, commissioning
decisions are still very much determined by government targets
and other "must-dos" such as NICE decisions and SHA
dictat.
The rationale behind commissioning: has the purchaser/provider
split been a success and is it needed?
The purchaser/provider split has educated the
provider organizations that their role is to deliver services
that are needed rather than on what they have historically delivered.
This has been and continues to be a difficult message for acute
trusts to assimilate. The bulk of health expenditure is spent
in the acute sector and yet delivers care to only the top 10%
of the health pyramid. Despite the wish to move funding from the
acute sector into the community, the power of acute trusts and
emphasis from government, (despite its rhetoric) on acute services,
care in the community is mainly theoretical.
Commissioning and "system reform": how
does commissioning fit with Practice-based Commissioning, "contestability"
and the quasi-market, and Payment by Results?
The logic of PBC is sound. The role of the GP
is not only to deliver personalised care but also to focus on
the total needs of its registered population. PBC falls down in
that the population and therefore resources are too small to manage
risk adequately and the administration costs duplicated. This
could be improved if practices worked in localities or federations
around a more sustainable population c70,000.
Contestability and the quasi-market rely upon
knowing what outcomes you want and being able to identify the
available resources. The tendering process should deliver more
cost effective services but it is time consuming and only suitable
for large contracts. PBC needs a speedier more flexible approach
to implementing change.
PBR was helpful initially to focus providers
on their activity. However now it stands in the way of real service
transformation. PBR focuses on activity not outcomes and does
not incentivise innovation. It makes collaboration between providers
difficult and basically encourages the status quo.
Specialist commissioning;
To look at specific areas of specialist care
with a large population makes sense. However it can also lead
to loss of ownership by the PCTs if they have no input into the
process and if their own identified priorities are subsumed.
For example the East of England SHA specialist-commissioning
group for IVF provision has imposed its decisions on all PCTs.
The dictat to provide all eligible couples with up to three fresh
IVF cycles diverts scare resources from local PCT priorities and
with no ring fencing of the budget allows no account of local
circumstances
Commissioning for the quality and safety of services.
This should be the number 1 priority but
in reality is often superceded by affordability and the choice
agenda. By more involvement of clinicians and patients in decision-making
this could be changed. This is political, as most GPs and probably
patients would rather sacrifice choice for an affordable quality
and safe service.
Personal view of why PBC has so far failed to
deliver its potential
— Failure of clinicians to understand
what commissioning means—and why should they as their
training is in delivering the best care for the person in front
of them? With the greater acceptance of the need for "distributive
justice" this is improving—and as clinicians begin
to understand the problem they come up with the solutions. GPs
are nearly there; acute clinicians haven't even reached the starting
blocks.
— Disempowerment of the GP—by
government, SHA, PCTs, acute care consultants. Good management
is about improving performance through support and education-
it is not about taking over. In any other profession a consultant
advises and hands back the problem—they do not take over
the problem.
— The blank cheque phenomenon—when
a GP makes a referral they have no idea what the final cost of
this transaction will be. Financial control is lost as soon as
the patient enters secondary care.
— Lack of performance review—without
feedback on which to reflect—behaviour change cannot occur.
Comparative data stimulates professional pride to improve—league
tables work.
— Medicalisation of health—the
public have been medicalised into patients. There is a need to
take back responsibility for their own health, learn to rationalise
risk, and work in partnership with health professionals.
— Managing expectation—too
much political fuelling of public expectation and emphasis of
rights over responsibilities. Public say they value the NHS yet
there is much wastage of resource especially medications and missed
appointments.
— Death—there needs to be
a recognition that death is a natural inevitable outcome of life.
Managing a good death is as important as prolonging a poor quality
life.
January 2010
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