8 more things wrong with GP commissioning

This is part 2. See also 10 things wrong with GP commissioning.

In a letter to GPs in September Andrew Lansley defined commissioning:

Many of you recognise that you take commissioning decisions already on a daily basis – when advising a patient whether to self-care, managing a patient directly, prescribing a medicine, or when referring a patient to a specialist for further investigation and treatment.The purpose of the proposed reforms is to give you and your colleagues in general practice – as people who see patients every day and understand their needs – the responsibility to shape sevices to deliver high quality care that your patients expect and deserve.

[The reforms] are about giving you the overall responsiblity for the design of services which meet your patients’ needs and to respond quickly when failures  in services arise.

1. Lansley clearly doesn’t understand commissioning. Commissioning is based on a purchaser-provider split. It is when GP purchasers pay specialist providers to do things for their patients, such as major operations, heart scans, chemotherapy, psychotherapy, intensive care stays etc. All the things we cannot do ourselves. The things we can do ourselves, advice, reassurance, prescribing etc. are not commissioning, whatever Mr Lansley says, unless he expects me to set up a contract with myself so that having diagnosed you with eustachian tube dysfunction I can then give you some advice and reassurance.

There remains a tricky, false distinction between what GPs do in their surgeries, e.g. minor surgery, blood tests, physiotherapy and what hospitals do. Therein lies the potential for conflict of interest if as a GP (purchaser) I commission myself to do work usually done by a hospital (provider)

2. We already shape services, we have been doing for years. In City and Hackney we have worked out Care Pathways so that GPs and our local hospital specialists work effectively together and our patients can be sure that up to date clinical guidelines are followed and the appropriate investigations are ordered in the right place at the right time. So patients referred for infertility treatment are investigated before referral so that hospital appointments are not wasted repeating tests that could have been arranged by the GP.

Care-pathways like this can save money by minimising hospital appointments and can improve quality of care by disseminating guidelines and sharing expertise between GPs and their hospital colleagues. We don’t need a £3bn NHS reorganisation to do this.

3. GPs are already handing the ‘responsiblity to shape services’ to international health insurance corporations.

I am signed up with my colleagues to become a commissioning pathfinder consortium. This is not because I approve of commissioning, but because I believe I must be responsible. Our local GPs almost unanimously oppose commissioning as proposed in the health bill, but we fear that if we refuse,  a private company will be given the job instead. In fact last month it was reported in Pulse:

NHS London has awarded a contract to the KPMG Partnership for Commissioning to support the development of pathfinders across the capital.

The partnership, claimed to be the first of its kind, sees KPMG teaming up with UnitedHealth UK, the National Association of Primary Care, Healthskills, NHS Primary Care Commissioning and legal firm Morgan Cole.

A move that outraged many london GPs who were not consulted, and most of whom are unaware of lawsuits regarding fraud by KPMG and UnitedHealth in the US. A pathfinder consortia in west london called the Great West Consortium has already employed UnitedHealth to to their commissioning for them.

A commissioning enthusiast, Shane Gordon, GP in Colchester and chief executive of the North East Essex GP Commissioning Group said this about private sector interest in his pathfinder consortium on his new DH blog:

“We’ve been inundated with offers of ‘help’ and training from every quarter. The difficult bit will be choosing which ones will really add value.”

Private companies are queueing up to get involved in commissioning. There are shareholder profits to be made here. That’s money that won’t be going on chemotherapy or joint replacements.

4. There is a conflict between patient choice and commissioned care pathways. In my original post, 10 things wrong with GP commissioning, I couldn’t figure out how patients could have choice unless we commissioned several versions of each service. Now I know. When I refer you to a specialist you can choose who you see from a list on a computer program called Choose and Book. On the website it says the one of the benefits of Choose and Book is that:

You can choose any hospital in England funded by the NHS (this includes NHS hospitals and some independent hospitals)

The providers that appear on Choose and Book are determined centally by the DH, not by your GP commissioner. You are allowed to choose ‘any willing provider’. This could (if a Patient’s Rights Directive goes through) include providers from all over Europe.

A patient came to see me having checked the NHS Choices website and discovered that the Royal London Hospital for Integrated Medicine was on Choose and Book for fertility treatement. She was amazed at the range of options that included Harley St clinics … on the NHS! But she wanted homeopathy, so she chose the Integrated Medicine hospital. So we have spent enormous amouts of time and energy designing a care pathway and it has disappeared amongst hundreds of ‘willing providers’.

GP commissioners will be controlling providers like we control the supermarkets. See this blog from Anna Dixon of the Kings Fund, Providers need to get their act together while commissioners look the other way and this report from the BMA News: “A GP leader has said foundation trusts could become so powerful that they undermine new consortia”

5. Monitor is a central agency to ensure competitiveness. It means that the ENT service we have designed with a local ENT surgeon and a GP with a special interest in ENT who see patients together in a local GP surgery may not be eligible because it costs more for the initial referral than other ENT services even though we have very high satisfaction rates and very low rates of follow up. This saves money in the long run and is more convenient for patients. You can see what services are provided and guidelines for GPs here.

With thousands of services already on Choose and Book, GP commissioning will be better described as GP de-commissioning. With £20bn of cuts, far more services like A&E and maternity departments will be closed, or de-commissioned like these than commissioned.

In a Redbridge PCT GPs have been told that they are only allowed to make 4 referrals a week. Draconian measures like this may be replicated by GP commissioners in order to save money.

6. Private providers will be able to ‘cherry pick’ elective services that are easy to replicate and will the be able to register centrally with the NHS Commissioning Board, bypassing the commissioning consortia. Private providers may be paid 14% more than NHS providers in order to make a ‘level playing field‘ for competitiveness. This means that existing hospitals will be in serious danger of not being able to offer services cheaply enough to survive and may go bust.

7. GP commissioning cannot drive up quality or drive down costs if it is driven by patient choice. When I refer patients, the vast majority just want the closest provider. But this may not be so simple in future. Where I work in East London there is a lot of choice, for example there are 100 dermatology choices within 30 miles of my surgery. The criteria which determine where providers appear on Choose and Book is determined by the DH and are distance from the surgery and waiting time. Other details are only available on the NHS choices website and include nothing to help judge clinical quality.

Of the 51 patients I referred out of 807 appointments I made in the last 3 months of 2010 none were interested in provider choice. In almost every case they had to go through a time-wasting, complicated process called choose and book, and in almost every case they chose the local service.

The government are expecting quality and cost improvements to come from patients and GPs being sufficiently picky about their secondary care providers, that the providers are forced to compete on price and quality, driving prices down and quality up. But it cannot happen with GP commissioning.

8. Patients’ will not be empowered. In the Guardian today Lansley stated, “But beyond institutional accountability, genuine patient choice will bring a dramatic level of direct accountability to NHS providers.” This is not the case as Andy Cowper’s perpetualy insightful policy blog explains. The plan to put patients at the heart of the NHS lacks any substance.

In summary.

GP Commissioning is being taken up because most GPs believe that we have to be responsible for our patients, and the alternative is that we will loose what little autonomy we still have because private corporations will be given the job instead.

At the heart of GP commissioning is the purchaser-provider split which is more accurately called the GP-Hospital specialist split. Safe, effective and efficient care needs GP-Hospital teamwork, not a split.

Quality health care depends on quality training, teamwork and regulation. Not competition.

There will be far more de-comissioning and closures than commissioning.

GP Commissioning will be a disaster for patients, GPs and the NHS.

Update 20.1.2012

GPC warns CCGs could face ‘bureaucratic nightmare’ on tendering. GP news online

Update 29.1.2012

GP commissioning. What lies behind the hard sell? Martin Mckee & Lucy Reynolds GP commissioning JRSM