Written evidence from Professor Martin
Roland (COM 129)
Professor Martin Roland, General Practitioner
and Professor of Health Services Research, University of Cambridge.
Oral evidence to be given 16 November.
1. The history of primary care led commissioning
in the NHS is not encouraging. GPs took slowly to the introduction
of fundholding in 1991. A few enthusiasts improved care for their
patients, but overall, the effect was modest. Inequalities in
care increased and GPs were not strategic in their purchasing
decisions. The limited initial scope of fundholding was extended
in 1995 under a scheme called "total purchasing", but
that model didn't really get going before it was abolished by
the incoming Labour government in 1998. Primary care trusts proved
to be risk averse, bureaucratic, and ineffective commissioners,
which led the government to revert to giving GPs notional budgets
under "practice based commissioning" in 2004. The effects
were again patchy, with GPs slow to get involved and with mixed
levels of enthusiasm. By 2009, substantial numbers were engaged
and starting to show some success in improving services. Despite
that, practice based commissioning was described by the government's
own primary care tsar as "a corpse not fit for resuscitation".
2. Despite this discouraging experience,
the idea persists that GPs hold the key to effective purchasing
of high quality care for their patients. Current proposals to
form GP commissioning groups will give them the biggest challenge
of a generation—with 75% of the NHS budget under the control
of GP practices. The risks of the scheme have been well rehearsed:
GPs don't want to hold budgets, they haven't got the skills, they
will need extensive management support, and multiple purchasers
will cause contracting chaos especially in big cities. In order
for GP Commissioning to be successful in its new guise, a number
of things are needed.
3. The first is for a sufficient number
of GP leaders. Not all GPs have to be actively involved in commissioning,
but substantial numbers do. Their motivation has to be to improve
care for patients. The Royal College of General Practitioners
sets out the values that define the profession—high quality
technical care, personal care, continuity of care, and a commitment
to individual patients that makes being a GP a profession rather
than just a job. The College will be providing advice and support
to GPs in their commissioning roles. This will be very important
at a time when support will also be offered by private corporations
who may not share these values. Management support for commissioning
will be a significant challenge as the commissioning reforms are
being brought during a period when the NHS plans a 45% reduction
in management costs.
4. GPs face a number of potential conflicts
of interest. Of these the most important is that GPs may have
a financial incentive not to refer patients even when they believe
that they would benefit clinically from a specialist opinion.
The second is that GPs as both commissioners and providers may
be able to commission care from themselves or from provider organisations
in which they have a financial interest. These conflicts of interest
will be easier to manage if GPs can neither make substantial personal
profits from commissioning nor put their practices at risk of
major financial loss.
5. The formula that government decides to
use to distribute budgets to GP commissioning groups has the potential
to cause major instability. An untested resource allocation formula
(the Carr Hill formula) was introduced with the 2004 GP contract
and had to be rapidly replaced as the sole basis for resource
allocation because it produced large and unexpected changes to
practice budgets. If the government pilots nothing else, it must
pilot a range of resource allocation formulas before giving commissioning
groups their budgets.
6. Commissioning groups will also have to
learn how to manage risk, either through arrangements that limit
the cost to their budget of individual patients, or by insuring,
or by pooling risk. They must make certain that patients with
complex or expensive needs can register easily with a GP and receive
the care they need.
7. GPs should generally form large geographically
defined groupings. This will reduce the turmoil that multiple
small purchasers will create, will allow them to be more effective
commissioners, and will help integration with community and local
authority services. However, they will need smaller subgroups
for quality improvement and clinical audit to be effective. One
size will not fit all the functions required of a commissioning
group. GPs must also develop close relationships with hospital
specialists and social care providers: purchasers and providers
must work together to deliver the integrated care that their increasingly
elderly populations need.
8. In developing and commissioning pathways
of care, GP commissioning groups will need to develop and maintain
close links with local specialists. This is essential to provide
the integrated care that the increasingly elderly population needs.
There is concern that the policy of allowing "any wiling
provider" to bid for services may prevent GPs developing
close links with specialists. Monitor must establish rules for
tendering which do not stand in the way of GPs and specialists
planning coordinated care for their populations of patients.
9. Government must be encouraged to have
the patience to see these reforms through. Major health service
reforms cause years of disruption and it may take four or five
years just to get back to where we are now. Research should inform
changes along the way, but two full parliaments will be needed
to know whether the latest commissioning experiment has been successful.
November 2010
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