GP-led Commissioning

The Health and Social Care Bill sets out how groups of General Practitioners (GPs), known as commissioning consortia, will be given real budgets to commission care on behalf of patients in their local communities.¹ Commissioning has been described as ‘the process of assessing the health needs of a population, then planning, securing and monitoring the best possible health services for that population, given the resources available.² Since 2005, commissioning has largely been in the hands of Primary Care Trusts (PCTs), with varying degrees of clinician involvement.

Evidence of the possible benefits

Together, consortia will be responsible for handling around £60bn of the NHS budget. They will also be given extensive accountability for local health outcomes, patient experience of health services, and financial performance with respect to their own budgets. The think tank, the Nuffield Trust, has described the move as ‘a logical one’ as GPs are in effect already responsible for most NHS spending through prescribing, patient referrals to hospital, and other clinical decisions.³ Possible benefits include giving GPs more negotiating ‘clout’ with their local hospitals, as the budget holders, and an opportunity to help tackle the wider health agenda. 2

However, although there are previous examples of GP commissioning, this level of responsibility will be new and the assessment of possible benefits is consequently largely speculative.

Evidence of the possible risks

On the other hand, there is evidence that previous forms of GP commissioning have had limited impact on improving hospital care. GP fundholders in the 1990s held a real budget to purchase community, outpatient and elective care for their patients. Participants were able to improve primary care services and make some short-lived efficiency savings⁴, whilst 15-20% were able to secure shorter waiting times and achieve lower referral rates. However, GP commissioners were not able to check rising expenditure on acute care⁵ or reshape hospital services significantly.⁶ This is important because demand for acute services continues to rise, in a time of economic austerity, and there is currently a need to reconfigure many services to deliver improvements in outcomes.⁷

Practice-based commissioning (PBC) was introduced in 2005, giving GP practices ‘indicative’ budgets with which to ‘buy’ health services for their population, although PCTs continued to hold legal responsibility for the money. In one study, PBC led to more collaborative relationships locally. However GPs noted that they had a limited amount of time to engage in PBC, and in many cases also lacked the requisite skills, for example in data analysis. The level of support they required from PCTs was therefore substantial.⁸ Another study concluded that it would be difficult to measure the impact of PBC, as there are no available controls. Small groups of highly motivated GPs led the scheme in most areas, but relationships with local hospital trusts were difficult, and wider service redesign proved difficult.⁹

Forms of GP commissioning have also been used internationally, including in the United States. There are several relevant lessons from this experience for the NHS:  fundholding by physicians can involve high transaction costs and result in major crises if funds run out of before the financial year ends; groups should be accountable for quality and patient experience, not just cost; and it takes time to create a high performing commissioning organisation. 2 Although the Government has placed a strong emphasis on reducing management costs, GP consortia will need high-calibre management and analytical support, as they are not used to acting as large conglomerates, handling millions of pounds. 3

Implications for health and well-being

This policy has implications for the quality of health care in England, which can in turn impact on the health of local populations. Previous NHS commissioning models, including GP fundholding, have largely failed to impact either health care expenditure or quality, largely due to a lack of influence over hospital activities which consume most expenditure.¹⁰ It is thus unclear whether or not the proposed model will enable GP commissioners to make significant improvements in the future.

Author: Helen Barratt, Wellcome Trust Research Training Fellow, Department of Epidemiology & Public Health, University College London.

UK area affected: England only