10 things wrong with GP comissioning

Edited on 18.7.2011. Now reduced to 8 things, but more serious than before, especially number 6.

1. The cost. The NHS reorganisations are estimated to be between £1.9bn and £3bn. Not only will the reorganisation be hugely expensive but the administration and transaction costs of running a market are vast. The last Health Select Committee reported that 20 years of commissioning in the NHS was a failure and had only led to increased transaction costs estimated to be 14% of the total NHS budget. It would have been far cheaper to increase clinical representation on existing PCTs than to completely scrap them and then set up GP commissioning consortia to do the same thing.

2. The numbers. There are not limits on the size of commissioning consortia. Historically PCTs have covered a geographical area and have been responsible for care of all the people in that area. PCTs are to be replaced with commissioning consortia. The Royal College of General Practitioners, based on international studies of similar organisations said that they should have a minimum of 300 000 patients in order to have a sufficient economy of scale to effectively commission the range of services their patient’s need. Many doctors warned that they should be co-terminous with local authorities and responsible for a geographically defined area. The government have allowed anyone to set up a consortia. There is a list of consortia here. In london they range from 7 to 67 practices in size. They are not obliged to cover a geographic area.This allows GPs to select the most efficient practices and avoid the least efficient. There is a serious risk of having an inadequate risk pool with a small consortia so that a few very expensive patients threaten the ability of the consortia to pay for other patient’s care.

3. The brain drain and the brains remaining. PCTs perform between 140 and 300 functions and have a broad range of analytical and managerial skills to do this. The proposed abolishment is leading to many of the best staff leaving already to work for private companies or to do something completely different. They are already falling apart. It remains to be seen how many experienced staff will be left to support GP commissioning consortia. Many consortia are already forming partnerships with the private sector, hastening the demise of a public NHS.

WThe majority of GPs don’t have any business or public health qualifications and we have barely any training for this. Our ‘business skills’ are learned ‘on the job’. We’re experts about dealing with our practice population, but don’t know very much about the needs of hospital or community services, or how to assess to the needs of large populations. We will have to re-employ PCT staff or involve the private and voluntary sector to perform the managerial, needs analysis, cost effectiveness, etc. work.

A report in the HSJ on 14.7.2011 showed that more than a quarter of those leaving PCTs had more than 15 years experience, 21% were clinicians and 21% worked in the most senior roles.

King’s Fund chief executive Chris Ham warned the NHS was “asset stripping the commissioning function, removing the very people and skills it needs to retain”.

There was a “serious risk” that the lost expertise would result in the NHS losing financial control, he said.

4. The conflicts of interest. If I think I am the best person to provide a musculo-skeletal assessment service and commission myself, there is a conflict of interest. How am I to separate my commissioning and providing functions? How are we to stop groups of GPs commissioning themselves and making Daily Mail headline salaries? There is a perception that we GPs are paid far too much (based on cases of individual GPs rather than any serious analysis). Converting the NHS into a business will see some GP entrepreneurs making absolutely whopping profits out of commissioning, as they did out of fundholding. Most, especially those looking after the most vulnerable populations will see their salaries fall significantly because there’s less money to be made looking after patients who behave inefficiently. I have written a post about conflicts of interest here.

5. The purchaser provider split. Commissioning reinforces, indeed depends on the split between GP purchasers and hospital and community providers competing for our patients and money. It makes effective collaboration desperately difficult, pits one hospital against another, and in a cash strapped environment forces decisions to be made about individual services without considering the wider health economy. Hospitals are loathe to work with GPs to reduce referrals because their income depends on more referrals, and GPs are desperate to reduce referrals to save money. Because of erverse incentives, gaming is rife with providers seeing to over investigate and operate and excessively review patients in order to earn more. Here a post about how it operates in a local hospital.

6. Patient choice. Before 1990 a GP could refer their patients anywhere in the NHS without having to set up a contract, or worry about gaming. Now GPs will most likely only have the resources to commission services from their local hospital but patients will be able to choose any ‘qualified provider’ in the NHS. In order to have effective market forces, patients will have to be tempted away from the services their GPs have commissioned.

In a speech health secretary Andrew Lansley made in 2005 (quoted in LeftFootForward):

“The statutory formula should make clear that choice should be exercised by patients or as close to the patient as possible, thereby maximising the number of purchasers and enhancing the prospects of competition.”

This explains why the government is transferring power and financial decisions to GP commissioners and ultimately to patients themselves with personal budgets. Providers will then be able to bypass GPs -who have vested interests in their patients using the services they have commissioned- by advertising directly to patients. The last thing the government and the private providers want is for GPs to be choosing where their patients go. The route to competition will be direct to consultant access even though we know it is extraordinarily expensive as they have discovered in France.  

7. The postcode lottery. Each consortia will choose to commission services for their own population which may have advantages, Tower Hamlets has very high rates of diabetes and City and Hackney has very high rates of drug and alcohol abuse so we might want more services for these problems than Totnes (for example) But if we want more of one thing we’ll have to spend less on something else (like fertility treatment)  There will be widespread differences in provision. Drug and alcohol services whilst necessary, don’t do much to increase satisfaction with the NHS or win votes (not compared to fertility treatment) There will be high profile media hysteria once the differences become wider and clearer.

8.  The bottom line. Tarifs, the set price for a medical service, are to be abolished, in order to encourage competing providers to provide the cheapest service. Not the best service or the most appropriate, but the cheapest. Quality is extraordinarily difficult (though not impossible) to measure. Price is easy. The government has set up an organisation called Monitor to ensure competition. There is a separate Care Quality Commission but there will be considerable tension between cost and quality, with the weight towards cost because we have to make such enormous (£20bn) savings. The government’s reassurance that there will be no competition on price has been investigated by blogger Dr No who has found it to be already rampant.

“Every shred of evidence suggests that price competition in healthcare makes things worse, not better” Zack Cooper. Price Competition could raise death rates… Health Service Journal

GP commissioning is unaffordable, will damage relationships between GPs and hospitals and will drive down patient choice. It needs to go.