Written evidence from The Nuffield Trust
(COM 66)
This submission of evidence is made to the Health
Select Committee by The Nuffield Trust, a charitable trust carrying
out research and policy analysis in health services.
SUMMARY
— The Nuffield Trust supports the concept
of clinically-led commissioning, and the associated principle
of maximising clinicians' involvement in health service planning,
funding and service development decisions. We believe that general
practitioners (GPs) and specialists should be jointly involved,
with the associated ability to take "make or buy decisions"
unrelated to personal income.
— We consider the recent White Paper proposals
to respond in part to the diagnosis we set out in our monograph
"Where next for commissioning in the English NHS?"
— In particular we welcome the allocation
of real and risk-adjusted capitated budgets to consortia of GPs,
along with responsibility for service quality and health outcomes.
— Our concerns about the proposals focus
on six issues:
— the likelihood that GP Consortia will
be unable to control expenditure any more successfully than PCTs
before them, at least in the short term;
— the focus on GP rather than wider clinical
commissioning;
— the decision to have a strict separation
between the commissioning and provider activity of consortia;
— the removal of the PCT as local system
manager;
— the statutory nature of GP consortia
and the potential consequences for GP engagement; and
— the extent to which GPs feel enthusiastic
and incentivised to get involved in commissioning in an active
manner.
1. INTRODUCTION
1.1 The Nuffield Trust has a mission to
promote improvements in the quality of healthcare and health policy,
with the aim of improving patient care and public health.
1.2 As a team we have been engaged in research
and policy analysis of NHS commissioning for over 15 years. Recent
relevant work includes:
— synthesis of research evidence and policy
analysis of possible commissioning futures (Nuffield Trust and
NHS Alliance,2009; Smith et al, 2010);
— two-year action research study of commissioning
of care for people with long-term conditions (funded by National
Institute of Health Research);
— development of person-based risk-adjusted
resource allocation formula for practice-based commissioning—used
in allocations across England from 1 April 2010;
— development of predictive risk techniques
for application to social care costs alongside health care costs
(Bardsley et al, forthcoming);
— policy analysis of the implications of
GPs assuming real budgets for commissioning (Smith and Thorlby,
2010); and
— international comparative study of primary
care-led commissioning, including the US, New Zealand, and Australia.
1.3 In this submission of evidence, we examine
four of the themes set out in the brief for this Inquiry, using
research evidence and our wider experience to draw out the key
lessons for policy and practice.
2. CLINICAL ENGAGEMENT
IN COMMISSIONING
2.1 Research evidence consistently underlines
the importance of effective and sustained clinical engagement
in commissioning.[33]
Primary care-led commissioning is predicated on a belief that
making clinicians directly responsible for health care resources
will encourage them to make commissioning decisions which are
more relevant to patients' needs and the specific local issues
in health service provision.
2.2 In a review of evidence on practice-based
and PCT commissioning (Smith et al, 2010) we concluded
that these recent forms of NHS commissioning had largely failed
to engage clinicians in a significant or sustained way. We suggested
that a more radical form of clinician-led commissioning should
be considered, as part of an overall strengthened continuum of
commissioning arrangements co-ordinated and held to account by
fewer and larger PCTs.
2.3 We support the proposal in the NHS White
Paper for GP commissioning consortia to hold real (as opposed
to indicative) capitated budgets for the purchasing of local health
services, and for these groups to be held to account for health
outcomes, patient experience of services, and financial performance.
GP consortia offer the promise of a more "real" form
of primary care-led commissioning that is likely to engage at
least some GPs in health planning, funding and service development
in a very active manner, and to enact changes without facing some
of the bureaucratic hurdles that proved a frustration with practice-based
commissioning.[34]
2.4 We do however have six main concerns
about the proposed policy on GP commissioning, issues that we
had anticipated in a briefing paper we developed in partnership
with five national organisations in May 2010.[35]
These six concerns are.
2.5 We believe that under the current plans
GP Consortia will be unable to control expenditure any more successfully
than PCTs before them. The likelihood is that in the short term,
consortia will be less likely to control expenditure (on hospital
care) because they will be in a process of organisational development
and under-resourced to do this job. To control hospital expenditure,
while achieving quality of care, consortia must link closely with
specialist colleagues in hospital, and invest in the management
and information infrastructure necessary.
2.6 We question the strict focus on GP rather
than wider clinical commissioning and in particular how consortia
will be incentivised to find ways of working closely with specialist
colleagues in community, mental health, and secondary care services
to develop new and more integrated services for patients. In the
current financial context, the main challenges faced by GP commissioners
(Dixon, 2010) will be in the areas of managing demand for hospital
care, reducing avoidable admissions,[36]
addressing large and unaccountable variations in clinical practice,
and developing integrated care for people living with long-term
conditions. Research evidence shows that primary care commissioners
in the past have focused mainly on extending primary and community
care services, and on marginal improvements in elective care,
struggling to have any impact on secondary care services (Smith
et al, 2004). In three recent monographs, the Nuffield
Trust has examined the ways in which GPs and specialists might
work together within multi-specialty groups to design and implement
new approaches to more integrated care.[37]
2.7 To have consortia focused purely on
commissioning raises questions about (a) how real this separation
of commissioning and provision can be and (b) if it is real, the
extent to which consortia will be able to lever desired changes
both from their colleagues across primary and secondary care,
and about the bureaucracy and transaction costs that may ensue.
One of the key strengths of primary care-led commissioning is
its ability to enable "make or buy" decisions where
clinical commissioners deliver as much care as possible within
practice-based settings, and then purchase other services that
maximise the possibility of more integrated care for patients.
We believe this separation between commissioner and provider could
lead to conflicts of interest (as in the case of GP fundholding)
which could undermine public trust in general practice. Arrangements
must be made to mitigate this potential conflict, in particular
by ensuring that the personal income of GPs (or in future, specialists)
is unrelated to savings made on commissioning budgets.
2.8 The removal of the PCT as the local
system manager. We believe that commissioning is most effectively
undertaken at different levels of the population, in order to
manage financial risk, for economies of scale, and to concentrate
necessary skills. In the post-White Paper world, services will
be commissioned through: personal health budgets; practice networks;
GP consortia; joint commissioning with local authorities; multi-consortia
networks; and the NHS Commissioning Board. There is a need to
determine who, in the absence of PCTs, will co-ordinate the local
"continuum of commissioning" (Smith et al, 2004),
and hold local providers to account, thus ensuring that services,
and more importantly patients, do not "fall through the cracks"
between organisations. Furthermore, it will be important for the
Department of Health and SHAs to ensure that extremely robust
local system management is in place during the period of transition,
especially in relation to financial control, clinical governance
and the meeting of the many statutory requirements currently located
with PCTs.
2.9 The decision to remove all PCTs from
the health system and make GP-led commissioning the main and statutory
health funding and commissioning bodies marks this reform out
from previous experiments with GP-led purchasing. This flies in
the face of UK and international research evidence on primary
care led commissioning which points to the importance of such
groups not being seen as "other" or as belonging to
the state but as being clearly owned and run by GPs (Nuffield
Trust and NHS Alliance, 2009; Casalino, 2010). The extent of financial
responsibility to be placed in the hands of GPs makes the statutory
nature of such consortia an inevitable and understandable decision.
However, research evidence suggests that the formality and extent
of such responsibility (in particular in a period of financial
austerity) may compromise the desire for engagement of front-line
practitioners.
2.10 It is questionable how far the majority
of GPs feel enthusiastic about, and engaged in, the idea of becoming
the main NHS commissioners. We know from research studies that
practice-based commissioning largely failed to engage GPs in a
significant manner and even GP fundholding in the 1990s, with
very clear and personal incentives for GP engagement, only reached
50% take-up after seven years. It is not yet clear what the incentives
will be for GPs to participate actively in GP commissioning. The
current suggestion is to link a proportion of practice income
to commissioning performance, although this is likely to be difficult
to implement in a manner that is sufficiently nuanced to provide
sufficiently direct personal incentives for GPs. Research also
highlights the importance, and the transactions costs, of commissioning
consortia spending time and energy in staying connected with constituent
practices and staff. This will be particularly challenging if
consortia are large in size.
3. ACCOUNTABILITY
FOR COMMISSIONING
DECISIONS
3.1 The move to GP commissioning should
give people a clearer sense of connection to their health commissioners
than is currently the case with PCTs, the latter largely lacking
local legitimacy and profile (Glasby et al, 2010; Thorlby
et al, 2008; Smith et al, 2010). Most people are
registered with, and use, GP services, with 80% of people having
contact with their GP in any one year.
3.2 It is possible that statutory GP commissioning
consortia will have public and/or non-executive membership of
their boards. Whilst this would clearly confer a degree of public
accountability, research suggests that wider involvement of other
stakeholders in clinical commissioning makes it harder to sustain
clinician engagement. The influence of patients, the public and
other health professionals at board level of primary care-led
commissioning has not often been significant in relation to strategic
decision making (Smith and Goodwin, 2006; Dowling and Glendinning,
2003). There will thus be trade-offs to be made between public
and professional engagement within new commissioning arrangements.
3.4 We anticipate that the NHS Commissioning
Board will quickly become the "headquarters of the NHS"
to which consortia will look for guidance, approval, performance
management, and direction—especially in the challenging
economic climate. Given the Board's proposed range of functions,
it seems to us likely that it will become large in size and need
to operate through regional outposts. Indeed, it will clearly
fall in part to the NHSCB to provide effective local system management,
along with GP consortia.
3.5 The NHSCB will have a critical role
as the overall funder of NHS commissioners, undertaking resource
allocation, designing templates for services, and holding GP commissioners
to account for their performance against the NHS Outcomes Framework.
It is as yet unclear how the role of the Board will relate to
the economic regulator and the Care Quality Commission. It will
be important that the regulatory framework for commissioning is
proportionate and not unduly cumbersome, since this could further
undermine the likelihood of effective GP engagement in commissioning.
3.6 The NHSCB will need to develop a failure
regime for GP commissioners, and the relationship of this with
the General Medical Services contract will be critical. The NHSCB
will hold the individual general practice contracts for GPs as
providers, as well as holding GP commissioning consortia to account.
This poses a question as to whether and how these two areas of
general practice activity will be jointly performance managed
at national level. National management of and accountability for
general practice service delivery appears to be a retrograde step,
considering the progress that has been made by many PCTs in managing
locally tailored practice contracts.
3.7 A key challenge within the new arrangements
is how hard choices will be made, and who will be held responsible
for these. We highlight two main issues, drawing on previous (Edwards,
2007) and current (Coster, forthcoming) Nuffield analysis of the
role and function of national independent health boards. First,
we would question how far the NHSCB will be able to remain truly
independent of the Secretary of State and the Department of Health
when faced with difficult local rationing decisions. We suggest
there is a need for formal circumscription of the scope of the
Secretary of State and the Department of Health to intervene in
the work of the NHSCB, albeit there will need to be arrangements
for the NHSCB to account to Parliament in an appropriate and transparent
manner. Second, there is a need for careful consideration of how
patients will respond to their GP if and when they know that s/he
is responsible for deciding what services are or are not funded
locally.
4. INTEGRATION
OF HEALTH
AND SOCIAL
CARE
4.1 In the short to medium term, the process
of transition from PCT to GP commissioning risks undermining vital
work to promote the integration of health and social care. Joint
working across the NHS and local government requires the nurturing
of long-term relationships between managers and professionals.
The restructuring of NHS commissioning typically entails changes
in key personnel, and the need for local government to get to
know new NHS leaders and to reorganise some of its own boundaries
and governance arrangements in order to work in an effective manner
with NHS bodies.
4.2 In the medium to long term, the move
of public health from the NHS to local government should enable
public health specialists to focus more firmly on the wider health
agenda and co-ordinate plans for housing, education, transport,
the environment and so forth with the work of the local NHS. There
is however a parallel risk of public health becoming divorced
from NHS service planning and provision, and of GP commissioners
finding it hard to access essential and timely public health expertise
in needs assessment, priority setting, service evaluation, and
the monitoring of health outcomes.
4.3 The proposal to establish local health
and wellbeing boards suggests a potentially stronger role for
local authorities in health commissioning, with public health
and local government coming together to provide overall scrutiny
of the work of GP commissioners. How far these LHWBs will have
"teeth" is difficult to say—they may be little
more than the "talking shops" that many previous joint
commissioning boards and groups have become. Alternatively, with
an appropriate degree of supervisory "clout" (as yet
undefined), they might start to take on the role of coordination
of the local health system, in the absence of the PCT and as a
statutory (and usually long-standing) local body that is well-known
to the public and has itself significant experience of commissioning
social and other care.
4.4 GP commissioning consortia will relate
to Health Watch, the Public Health Service, and to local health
and wellbeing boards, yet research evidence suggests that this
may prove challenging (Smith and Goodwin, 2006; Dowling and Glendinning,
2003). GP commissioners typically prefer to focus on clinical
service commissioning reflecting their training and experience
and have historically been less willing to engage with broader
population health commissioning. In respect of developing patient
engagement mechanisms, GP commissioners will arguably face a conflict
of interest as providers of local services, and may need external
support to carry out this function.
4.5 Given that NHS commissioning arrangements
are being reformed at a time of health and local government financial
constraint, it will be important for LHWBs, together with GP and
social care commissioners, to be able to track changes in the
use of NHS and social care for specific patient groups. Data linkage
work pioneered by the Nuffield Trust enables an assessment to
be made of utilisation of health and social care services at a
person level. This provides a basis for commissioners to explore
potential substitution of NHS care for social care and vice versa.
5. RESOURCE ALLOCATION
5.1 The allocation of resources to GP commissioning
consortia will entail the balancing of incentives for more efficient
care against the need to ensure that sufficient funds are available
to tackle local health needs. This will be particularly challenging
where commissioning consortia do not align with historical geographic
boundaries. At present there is a set of methods for resource
allocation for hospital care from the Department of Health to
PCTs, and another for allocations by PCTs to practices, based
in part on a person-based formula. The person-based approach (developed
by a consortium led by the Nuffield Trust) is based on predicting
future use of hospital care by exploiting information on primary
and secondary care at the person level. This approach has shown
that it is possible to estimate a risk-adjusted capitated budget
that is driven by the individuals within a registered population
base. As such it offers a way of setting budgets for commissioning
consortia in a way that does not depend on aggregating geographic
areas.
5.2 A person-based approach to resource
allocation could also be used to calculate budgets for multispecialty
groups of primary and secondary care doctors, enabling aligned
incentives for these clinicians to work together to maximise health
gain and service efficiency across sectors. Such multispecialty
groups could compete with one another for patients and hence offer
choice for users, as explored in a Nuffield/King's Fund monograph.[38]
5.3 Policy decisions will need to be made
as to which methods should be used for allocation of funding to
GP commissioning consortia, and the extent to which the NHSCB
thinks it appropriate to direct the method of allocation within
each consortium. In part this will depend on how GP commissioning
consortia function, in particular the extent to which they hold
the budget rather than practices, or use other means to ensure
greater equity in access to care for the population on the basis
of health needs, for example through identifying and reducing
unwarranted variations in clinical practice. Three critical elements
for the future application of these approaches are:
— The need to combine allocation mechanisms
across the care spectrum—at present the model focuses on
the high cost acute sector. Ideally it should include mental health,
maternity and community based provision and arguably also social
care.
— There is a need for mechanisms to
share some risk across small populations so that consortia budgets
are less likely to be destabilised by the chance appearance of
a small number of a very high cost patients.
— Implementation of these models requires
a flow of information, at the person level, about care provided
and individuals' health needs. Future commissioning organisations
will need to ensure that good quality information is both collected
and that the systems and structures exist to combine and analyses
that information within and across commissioning groups
6. CONCLUSION
6.1 The Nuffield Trust supports the concept
of clinically-led commissioning, and the associated principle
of maximising clinicians' involvement in health service planning,
funding and service development decisions. We believe that GPs
and specialists should be jointly involved, with the associated
ability to take "make or buy decisions" unrelated to
personal income.
6.2 We consider the recent White Paper proposals
to respond in part to the diagnosis we set out in our monograph
`Where next for commissioning in the English NHS?' In particular
we welcome the allocation of real and risk-adjusted capitated
budgets to consortia of GPs, along with responsibility for service
quality and health outcomes. Our concerns focus on six points:
— The likelihood that GP Consortia will
be unable to control expenditure any more successfully than PCTs
before them, at least in the short term.
— The focus on GP rather than wider clinical
commissioning.
— The strict separation between the commissioning
and provider activity of consortia.
— The removal of the PCT as local system
manager.
— The statutory nature of GP consortia.
— The extent to which GPs feel enthusiastic
and incentivised to get involved in commissioning in an active
manner.
REFERENCESBardsley
M, Billings J, Chassin L et al (forthcoming) Predictive
models for health and social care: a feasibility study. London,
the Nuffield Trust.
Blunt I, Bardsley M and Dixon J (2010) Trends in
emergency admissions in England 2004-09: is greater efficiency
breeding inefficiency? London, the Nuffield Trust.
Casalino L (2010) Motivating GPs to hold risk-bearing
budgets: lessons from the US. Nuffield Trust and King's Fund seminar
on GP commissioning, 9 June, 2010.
Coster G (forthcoming) Reflecting on the New Zealand
National Health Board. London, Nuffield Trust.
Dixon J (2010) Making progress on efficiency in the
NHS in England: options for system reform. London, the Nuffield
Trust.
Dowling B and Glendinning C (2003) The New Primary
Care: Modern, Dependable, Successful? Maidenhead, Open University
Press.
Edwards B (2007) An independent NHS: a review of
the options. London, the Nuffield Trust.
Glasby J, Dickinson H and Smith JA (2010) Creating
NHS Local: the relationship between English local government and
the National Health Service. Social Policy and Administration
vol 44, no 3, pp 244-264.
Ham C and Smith JA (2010) Removing the policy barriers
to integrated care in England. London, the Nuffield Trust.
Lewis R, Rosen R, Goodwin N and Dixon J (2010) Where
next for integrated care organisations in the NHS? London, the
Nuffield Trust and King's Fund.
Nuffield Trust and NHS Alliance (2009) Beyond Practice-Based
Commissioning: the local clinical partnership. London, the Nuffield
Trust and NHS Alliance.
Smith JA, Curry N, Mays N and Dixon J (2010) Where
next for commissioning in the English NHS? London, the Nuffield
Trust and the King's Fund.
Smith JA and Goodwin N (2006) Towards managed primary
care: the role and experience of primary care organisations, Ashgate
Publishing, Aldershot.
Smith JA, Mays N, Dixon J, Goodwin N, Lewis R, McClelland
S, McLeod H, Wyke S (2004) A review of the effectiveness of primary
care-led commissioning and its place in the UK NHS. London, The
Health Foundation.
Smith JA and Thorlby R (2010) Giving GPs budgets
for commissioning: what needs to be done? London, The Nuffield
Trust, King's Fund, RCGP, NAPC, NHS Alliance and NHS Confederation.
Thorlby R, Lewis R and Dixon J (2008) Should primary
care trusts be made more locally accountable? A discussion paper.
London, The King's Fund.
October 2010
33 Smith JA, Curry N, Mays N and Dixon J (2010) Where
next for commissioning in the English NHS? London, the Nuffield
Trust and the King's Fund: http://www.nuffieldtrust.org.uk/publications/detail.aspx?id=145&PRid=694. Back
34
Nuffield Trust and NHS Alliance (2009) Beyond Practice-Based Commissioning:
the local clinical partnership. London, the Nuffield Trust and
NHS Alliance: http://www.nuffieldtrust.org.uk/publications/detail.aspx?id=145&PRid=659. Back
35
Smith JA and Thorlby R (2010) Giving GPs budgets for commissioning:
what needs to be done? London, The Nuffield Trust, King's Fund,
RCGP, NAPC, NHS Alliance and NHS Confederation. http://www.nuffieldtrust.org.uk/publications/detail.aspx?id=145&PRid=712. Back
36
Blunt I, Bardsley M and Dixon J (2010) Trends in emergency admissions
in England 2004-09: is greater efficiency breeding inefficiency?
London, the Nuffield Trust: http://www.nuffieldtrust.org.uk/publications/detail.aspx?id=145&PRid=714. Back
37
See Lewis R, Rosen R, Goodwin N and Dixon J (2010) Where next
for integrated care organisations in the NHS? London, the Nuffield
Trust and King's Fund: http://www.nuffieldtrust.org.uk/publications/detail.aspx?id=145&PRid=693;
Nuffield Trust and NHS Alliance (2009) Beyond Practice-Based Commissioning:
the local clinical partnership. London, the Nuffield Trust and
NHS Alliance: http://www.nuffieldtrust.org.uk/publications/detail.aspx?id=145&PRid=659;
and, Ham C and Smith JA (2010) Removing the policy barriers to
integrated care in England. London, the Nuffield Trust: http://www.nuffieldtrust.org.uk/publications/detail.aspx?id=145&PRid=721. Back
38
See Lewis R, Rosen R, Goodwin N and Dixon J (2010) Where next
for integrated care organisations in the NHS? London, the Nuffield
Trust and King's Fund: http://www.nuffieldtrust.org.uk/publications/detail.aspx?id=145&PRid=693 Back
| 
