Written evidence from Dr Peter Davies
(COM 127)
THE NEW
COMMISSIONING LANDSCAPE:
A GP'S VIEW
Speaking personally rather than on behalf of
any organisation.
The NHS white paper, "Liberating the
NHS" is a major challenge to GPs, and to the NHS as a
whole.
Up till now individual doctors and other health
professionals have tended to practice medicine on a deontological
ethic—namely the duty of one person to another. The relationship
has been personal, private, and mostly confidential. The decisions
made (hopefully in a sensible, patient centred and evidence based
manner) have then been enacted.
These clinical decisions result in prescriptions,
investigations, referrals, operations, rehabilitation and use
of other services. These all have significant costs attached.
Up till now the NHS has picked up the bill for these. At the doctor-patient
level the costs are not often mentioned. In the limit however
health secretaries are always under pressure to yield on costs
as the doctors can "shroud wave" saying, "my patient
needs this treatment, and look the NHS is not funding it."
The Scots remind us that, "there's nae pockets in a shroud."
The NHS as a whole is a utilitarian enterprise.
It is on the whole a good pooled risk shared insurance scheme
into which we pay collectively, but use freely as individuals
when the need arises. However a health system raises money (tax,
user charges, employer contributions) the amount of money in any
health system is always finite. Any health care system has three
functions—namely revenue raising, revenue distribution and
spending on services.
There is a conflict between the utilitarian
ethic of the NHS system (wanting to do as much good as it can
for as many people as possible, but accepting it will never do
everything for everyone, no matter how well funded it is) and
the deontological nature of the individual doctor-patient interaction.
(wanting to do our best for each single patient, to a large extent
oblivious of everyone else).
The new commissioning plans will bring this
conflict out into the open. As a doctor I will start to think
that I have done a morning's work, and seen so many patients and
spent so much on running my surgery, so much on tests, so much
on prescriptions, so much on referrals. I am going to have to
become far more conscious of how much NHS (taxpayer's) resource
I am committing to my recommendations to my patients. At one level
this is good—it makes my work and its clinical and cost
effectiveness more transparent. At another it may become obvious
that rationing is occurring at the level of the GP-patient interaction.
GPs (and GP commissioning consortia) will need support (protection
from complaints, protection from media howls) when this occurs.
If this support is not forthcoming then the GP front line of the
NHS will collapse and efficient use of NHS resources will become
impossible.
With this White Paper Andrew Lansley has given
me as a GP a massive challenge. For many years GPs have prided
ourselves on our relative cheapness and our "gatekeeper"
role. Well these reforms will test out whether we do perform this
role as well as we like to think. If we can deliver successfully
on these reforms then we will deserve much credit. If we do not
we will probably fail badly, as other commissioners have done
before us.
The new GP commissioning consortia may bring
out a group of well informed industry insiders as managers- people
who actually know their field well, and its strengths, weaknesses
and pitfalls. The evidence I have read recently (eg Geoff Colvin's
book "Talent is Overrated" Nicholas Brearley
Publishing 2008) is that "general management" is a chimera
and that the strongest industries bring through people who combine
technical with managerial knowledge. The old PCTs tended to have
limited clinical engagement, and so for example you could see
the absurdity of a "clinical safety meeting" taking
place with no doctor or nurse involved.
There are many unknowns with these new proposals.
They represent significant extra work and significant challenge
to me personally, to my practice, my local area and to GPs as
whole.
Personally I am quite optimistic about these
proposals seeing many opportunities in them for myself and my
profession to deliver better services to patients. In particular
if the proposals are implemented so that clinicians can streamline
local services on a systems based approach (eg as described by
John Seddon in "Systems Thinking in the Public Sector:
The Failure of the Reform Regime|. and a Manifesto for a Better
Way". Triarchy Press, 2008) looking at patient flow through
the NHS system then there is a chance to improve how whole systems
work. A frustration of many GPs is that they try to do their part
of the work well, but struggle when care passes onto other agencies
eg Community Mental Health Teams, and the handovers are slow,
and awkward, and professionals are trying to guess who has said
and done what. Fragmentation of care is costlier and riskier than
continuity of care. If GPs and the commissioning consortia are
allowed to break down the many NHS silos (see p 26 of Davies and
Gubb Putting Patients Last—Civitas, London 2009,
or Commandment 3 p 45 of "The Ten Commandments of Business
Failure" Donald Keough, Penguin 2008) then much progress
could ensue—that could be more efficient in terms of patient
journeys and in terms of smooth economics—the NHS squanders
money on silly administrative delays that could well just disappear-
to everyone's benefit.
However I can see many dangers as well:
— The number of roles and posts open to
GPs expands so we end up as a scarce resource- or we end up each
trying to do too many things.
— Many GPs struggle to get their heads
around the logic of these changes and retire or move away.
— There will be a large need for education
in budget management and commissioning skills—even those
of us who can see the logic of these proposals may have more enthusiasm
than skill for implementing them. At present as a GP I can read
my practice accounts covering turnover of about £1.2 million
per year with reasonable comprehension. The local PCT.'s budget
is about £220 million per year. My practice's commissioning
budget for hospital activity and prescriptions for our patient
list of 10,800 is £3,663,503 per quarter (April to July 2010
figures, about £14.65 million annually) or an annualised
averaged cost of £612 per patient on hospital activity and
£167 on prescriptions. On these figures my practice is spending
about 10% more on clinical activities than planned against our
indicative budget. It is only in the last year or so that I have
come to have this kind of figure readily available, and begun
to discuss it with colleagues. The PCT is not yet looking to alter
the behaviour of individual practices specifically but is aware
of its large "overtrade" with the acute sector, and
the need to reduce this.
— The management role is under funded—and
so GPs stay in their surgeries rather than get involved in complex
and poorly remunerated PCT work.
— The policy fails to bed in and is changed
again in five years time—after all White Papers come and
White Papers go, and still there are civil servants writing another.
— The national tariff does not adapt quickly
enough to allow consortia to justify changes in practice. Meanwhile
providers swallow up ever more resources via payment by results.
— The National Tariff drives fragmentation
and itemisation of care, rather than its integration.
— Local commissioners need authority to
make the right locality decisions and trust that the centre will
back the periphery if any questions or conflicts arise.
— Acceptance of variation between localities
will become necessary. Different areas will make different decisions
with different outcomes. Cries of "postcode lottery"
will need to be drowned out by cries of "local needs met"
and "local priorities set and achieved."
November 2010
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