The answer to the questions that remained after yesterday’s post
Q.Why are private companies queueing up to ‘help’ with GP commissioning and why are some GPs so enthusiastic?
A. Because of the profits
To quote the bill: “The board may, after the end of a financial year, make a payment to a commissioning consortium if, in the light of an assessment carried out under Section 14Z1, it considers that the consortium has performed well during that year . . . A commissioning consortium may distribute any payments received by it under this section among its members in such proportions as it considers appropriate.” These payments will be made every year. There’s no need to wait and see whether this system will damage care down the line. There is a clear financial incentive to do exactly as Lansley directs.
Q. How will they make money?
A. By rationing care. As Shane Gordon, chief executive of the North East Essex GP Commissioning Group pointed out in his DH blog,
unfettered choice = cost pressures ++
Or as two senior policy advisers said last week on twitter,
cannot see gpccs shaping markets, they will be buying off the shelf. Patient choice + awp [any willing provider] = no commissioning
In other words, patient choice is too expensive. We can either have patient choice and any willing provider or GP commissioning. But not both. And with £20bn cuts to make, choice will have to go. We can commission some services such as A&E and other emergency/ unplanned (acute) care. But this alone will not make the £20bn savings demanded by Lansley. To save money commissioning will have to severely restrict patient choice and/or reduce the amount of money paid to the providers.
They can do this in different ways.
Redbridge PCT has limited GPs to just 4 referrals a week. So if you’re in need of a specialist and a GP has used their quota, you have to wait and see if they have less referrals the following week, or wait for your GP to appeal.
My PCT, City and Hackney has bought out a long list of ‘de-commissioned’ services. As a result, one woman who had a gastric bypass operation 3 years ago has been refused funding for surgery to remove the excess skin that is hanging off her now that she weighs 12 stone less than she used to. When she had the original surgery she was told that the excess skin removal was part of the service. Not any more.
Another way to save money is for commissioners to refuse to register high cost patients. As extraordinary as this sounds this was a warning from Clare Gerada, head of the Royal College of GPs this week. The NHS has an enormous risk pool, meaning that the costs of one patient within the entire NHS are negligible, but the risk pool is being divided up into several hundred consortia so that a few very expensive patients could have a significant impact on the budget for a single consortia. For example if a few people need very expensive intensive care or cancer drugs they could seriously reduce the amount of money left for other patients (and the commissioner’s profits)
Another way is to only allow referrals to the cheapest providers. Since providers can compete to provide the cheapest service, this will be possible. But everyone agrees that competition on price in healthcare is dangerous because it leads to a deterioration in quality.
“Every shred of evidence suggests that price competition in healthcare makes things worse, not better” Zack Cooper. Health Service Journal
All of these potential solutions will restrict choice so patients will have very little say in their referral. GPs will have to select from a short list of value-for-money providers and quality will suffer.
The transformation of the NHS from a public service into series of businesses and the conversion of patients and healthcare into commodities is dangerous and foolish ideology.