Written evidence from Professor Margaret
Whitehead (CFI 50) (WH Duncan Professor of Public Health, University
of Liverpool)
PUBLIC HEALTH
IMPLICATIONS OF
THE SHIFT
IN COMMISSIONING
FROM PCT GEOGRAPHICAL
POPULATIONS TO
GP CONSORTIA
1. The session is specifically concerned with
how the NHS reforms will affect resource allocation, given that
there is to be a shift from PCT weighted capitation allocations,
based on geographic populations, to consortium allocations, based
primarily on patients registered with GP practices. The concern
from a public health perspective is that the shift from PCT commissioning
to GP consortia commissioning raises potential problems that include,
but are much wider than, the resource allocation issue. The switch
to commissioning through GP Consortia will undermine one of the
fundamental mechanisms by which the NHS strives to ensure
good geographic access to a full range of services wherever people
live. Currently PCTs have responsibility for all the people resident
within defined geographic areas, not just the patients registered
with specific health services. This allows for long-term needs
assessment, planning and commissioning of services to match those
needs, as well as accountability of public employees for the use
of the resources allocated for that population, measured against
outcomes that are also population-based. The proposals in the
Bill abandon the population-based principle for the first time
in the NHS's history. With GP Consortia, the basis of commissioning
is for registered patients only, within the patchwork boundaries
of each consortium, which have no well-defined geographical footprint.
The ability to assess needs of people living in each area and
plan for the proper geographic distribution of services for communities
and local populations will be lost if this essential requirement
is not met (Whitehead et al, 2010).
2. The technical difficulties of monitoring GP
Consortia for performance, governance and accountability for health
and health service outcomes will be immense without a well defined
geographic population denominator, but there has been little or
no consideration of this, at least not in the public domain. The
focus so far seems to have been largely on financial accountability
mechanisms. Consideration now needs to the given to how GP consortia
will gain the necessary public health input that they require
in the commissioning process, as well as how this specialist expertise
should be funded.
RESOURCE ALLOCATION
FOR GP CONSORTIA
COMMISSIONING
3. Since its inception, the NHS has been based
on the principle of "equal access for equal need". This
principle is embodied in two longstanding objectives for resource
allocation from the centre to local health services:
- (i) To distribute resources based on the
relative need of each area for health services. Currently, this
objective is to enable PCTs to commission the same levels of health
services for populations with similar needs;
- (ii) In addition, to contribute to the reduction
in avoidable health inequalities (DH, 2011).
The resource allocation formula devised to meet these
objectives includes the age profile of the population (localities
with more elderly populations have higher needs, all else being
equal); additional need over and above that relating to age (localities
with less healthy populations and higher levels of deprivation
have higher needs, all else being equal); and unavoidable geographical
differences in the cost of providing services—the Market
Forces Factor (MFF) (it costs more to provide the same level of
services in high cost areas such as London and the South East).
From 2008 onwards, a separate component has been included in the
formula to meet the objective of contributing to avoidable health
inequalities. The indicator used was disability-free life expectancy
(DFLE), which is the number of years from birth a person is expected
to live which are free from limiting long-term illness and disability.
DFLE exhibits a strong socio-economic gradient, decreasing with
increasing deprivation, making it a reasonable choice of indicator
in relation to health inequalities.
Both these objectives need to be embodied in the
new NHS system, but it is made extremely difficult by the loss
of responsibility for a defined geographic population. It is unclear,
for example, if and how a measure such as DFLE could be derived
for GP Consortia, given their irregular, non-geographic footprints.
4. In this and any future resource allocation
formula, it is essential to take deprivation into account not
only because the prevalence of ill-health increases with increasing
deprivation, but also because of the higher likelihood of patients
having multiple, interacting health problems which makes their
treatment more complex and costly. In addition, living in poorer
socioeconomic circumstances may impede recovery and make it "harder
to reach" them with the services they need. Some geographic
population basis needs to be retained.
CREAM-SKIMMING
AND PERVERSE
INCENTIVES
5. The fact that more disadvantaged populations
have a higher disease prevalence and more complex conditions means
that caring for them may be more difficult and costly. There are
significant implications stemming from this in the move towards
a more market-driven NHS system, not least the issue of cream-skimming
(the practice of selecting "easier to serve"/less costly/more
profitable patients). There is a danger of cream-skimming in the
new NHS structures which was not present with PCT commissioning.
PCTs are responsible for a population allocated to them within
a defined geographic boundary—there is no possibility of
picking and choosing the people within that designated area. GP
Consortia, however, will not have that constraint. They can pick
and choose which practices are members of the consortium: those
practices based in disadvantaged communities could be shunned,
for instance, while those in more affluent areas could be encouraged
to join. There may be practices that no consortium is keen to
take on board, simply because of the socioeconomic profile of
their patients.
6. There is also the possibility of increased
cream-skimming by GP practices when practice boundaries are removed
and patients are able to register with any GP practice, theoretically
anywhere in the country. There will be no obligation on practices
to accept patients from the local area in which the practice is
based if other, "easier to serve", patients from elsewhere
come forward for registration. One consequence of such a process
could be the creation of the converse: "sink practices"
which contain the less profitable patients with the more complex
conditions. There is evidence that cream-skimming of this nature
went on under the GP Fund-holding initiative in the 1990s, and
any perverse incentives to do so in the new NHS reforms need to
be addressed, presumably by the NHS Commissioning Board.
7. A related challenge for the NHS Commissioning
Board will be to do something about the distribution of GPs, which
has become less equitable, year-on-year, since the early 1990s,
made even worse since the abolition of entry controls in 2002
(Goddard et al, 2010). These controls regulated the setting
up of new GP practices in over-served areas, with the aim of encouraging
more provision in under-doctored, more deprived areas. Remedying
this will require targeted area-level policies.
8. The accelerated drive to "cleanse"
GP lists of "ghost" patients in preparation for the
switch to GP Consortia Commissioning could result in another form
of cream-skimming. Reports in the GP journal Pulse claim
that up to 40% of patients could be stripped from practice lists
under tough new measures to clean the databases of registered
patients on which resource allocation to Consortia will be based
(Pulse, 2 March 2011). In one pilot scheme in NHS Brent, every
patient who has not visited their surgery within six months and
who fails to respond to two written notices will be wiped from
targeted practices' lists. This exercise was designed to cut costs
by stripping out patients who have died or moved, but it also
risks removing whole swathes of the local population who have
very real and on-going needs for health care but who have not
used the primary care services in the previous few months. This
could affect, in particular, elderly people, those who are disabled
or mentally ill, ethnic minorities and people in high deprivation,
high turn-over areas. Lists of some GP practices with a high proportion
of patients from high deprivation, high turn-over areas could
be particularly hard hit by this cleansing and could face closure
as registered numbers fall. Much of this is currently speculation,
but requires further investigation.
PUBLIC HEALTH
ALLOCATIONS FORMULA
TO LOCAL
AUTHORITIES
9. The current resource allocation formula contains
a component to address the second NHS resource allocation objective:
"to contribute to the reduction of avoidable health inequalities".
There is debate about whether this element should be removed from
the formula that will distribute resources to GP Consortia and
instead be covered by the formula currently being developed for
the transfer of the public health budget to local authorities
and the proposed "Health Premium". The first point to
be made about this proposal is that even if the health inequalities
objective were to be built into the local authority public health
resource allocation formula, the move would still only partially
address that second objective. There would still be a need for
an element in GP Consortia Commissioning budget for reducing inequalities
in access to GP commissioned services that may contribute to the
observed inequalities in health status. In addition, the NHS Commissioning
Board would need to ensure the continuation of public health activities
carried out by GPs as part of the essential services they provide
for all patients.
10. Under the Public Health White Paper, local
authorities will have a new statutory duty to improve the health
and well-being of their local population, and possibly for other
duties, such as elements of health protection. A ring-fenced budget,
weighted for health inequalities, will be allocated to upper tier
and unitary authorities in local government for this purpose,
based on target allocations determined by an allocations formula
and drawn from the former NHS budget for such public health activities.
The development of a formula for this purpose will have the advantage
over the formulae for allocation of funds to GP Commissioning
Consortia in that it will have a defined geographic population
base: people residing within local authority boundaries. The consultation
document puts forward three general approaches for establishing
the public health formula: a "utilisation" approach
based on current patterns of public health activity and indicators
of need; a "cost-effectiveness" of public health spend
approach, and one based on "population health measures"
within the LA areas. The utilisation approach is inadequate because
variations in spend on narrowly defined public health activities
are likely to be poor indicators of relative need across local
authorities, as well as there being a lack of comprehensive data
on activity and costs at the required spatial level. Likewise,
the cost-effectiveness approach suffers from a paucity of evidence
on the cost-effectiveness of public health interventions, as well
as being fraught with data and methodological issues. The third
approach is the only sensible choice from a conceptual and practical
perspective. Measures such as standardised mortality rates and
ratios, life expectancy and disability-free life expectancy are
all available at the LA level and are indicators that demonstrate
a strong socioeconomic gradient. If incorporated into the formula,
one or other of them could indicate increased need requiring additional
resources for public health activities.
THE HEALTH
PREMIUM AS
A PERVERSE
INCENTIVE
11. In addition to the above public health allocation,
there is a proposal in the Public Health White Paper to introduce
a new "health premium" to incentivise action to reduce
health inequalities. This will only apply to that part of the
local public health budget that is for health improvement. The
proposal is for local authorities to receive an incentive payment,
termed a "health premium", depending on the progress
they have made in improving the health of the local population
in general and of improving the "the health of the poorest
fastest". Possible public health outcomes indicators have
been put forward for consultation on their potential to measure
the required progress. Over and above problems of availability
and robustness of the data at the required spatial level, there
is a fundamental problem with the proposed indicators, related
to the purpose to which they are put. While several of the proposed
indicators might work as indicators of increased need in
an area, if used as indicators of improved outcomes they
could simply deliver the premium to areas where it is easier and
faster to make progress, which may well be the more affluent areas
around the country. There needs to be a re-consideration of the
use of financial incentives for public health outcomes from both
practical and ethical perspectives.
March 2011
|
