NICK GOODWIN
PhD
Senior Fellow, Health Policy
King’s Fund
Nick’s work interest in healthcare policy and management spans 20 years and a varied portfolio, including the organisation and management of primary care, commissioning and integrated care. Nick is a Fellow of the Royal Geographical Society and a lapsed sportsman and armchair explorer. He is happily married with a beautiful one-year-old daughter
My professional career started as a fresh-faced researcher with The King’s Fund in the early 1990s, where I was asked to review the evidence on the impact of GP fundholding – a highly controversial scheme designed to provide GPs with budgets to purchase care directly for their patients.(1) Subsequently, I worked for three years as a part of a national evaluation of 52 total purchasing pilots that, in most respects, have been replicated through the practice-based commissioning (PBC) model of today.(2)
It was thus with a considerable sense of déjà vu on my return to The King’s Fund in 2007 to find that it should be running a two-year investigation into PBC. The key findings in the resulting report – the lack of proactivity among GPs and the long list of barriers to progress – were, to me, entirely predictable given the back catalogue of evidence.(3)
In my mind, the evidence on “what works” had been ignored due to a combination of policy amnesia and the NHS’ acute lack of corporate memory that attributed universal benefits to the former fundholding models that were, at best, overstated and, at worse, misrepresented. As a result, the PBC policy has not lived up to expectations or delivered its intended benefits.
What went wrong? Analysing the barriers to progress
Despite demonstrable “success” in a number of localities, PBC has overall made limited progress in meeting any of its key objectives. The key barriers, as articulated in the King’s Fund report and the Department of Health’s recent “reinvigoration guidance”,(3,4) include:
- Conflicting visions. The lack of a clear vision for the policy has led to conflicts and tensions locally. GPs, on the whole, have regarded PBC as an opportunity to provide a range of new services in practice settings while primary care trusts (PCTs) have sought clinical engagement in care pathway redesign and/or in helping to manage healthcare resources – typically through referral management schemes.
- Roles and responsibilities. Disagreements between PCTs and GP practices over their roles and responsibilities have resulted from their conflicting visions for PBC at the local level. This has often led to a “power play” between PCTs and practice-based commissioners as they struggle for control of the PBC agenda, rather than enabling the fostering of partnerships characterised by good relationships and mutual trust.
- Lack of prioritisation. PCTs have generally regarded PBC as a low priority. It was common for PCTs to report that there was little in the world class commissioning framework to incentivise PBC or hold them to account for delivering the necessary support to make it work. The ability and willingness of GPs to make PBC a priority has also been limited given their obvious commitments to their “core” work in general practice and the relative lack of incentives to participate.
- Capacity and capability. Significant shortcomings in the availability of skilled staff with the necessary time to support PBC is widespread. The lack of adequate leadership and management support has been characteristic of most people’s experiences of PBC so far.
- Data. A lack of reliable and timely data has undermined PBC in a number of ways – from setting and managing budgets, to building business cases for service investment, to questioning the validity of secondary care activity and unbundling tariff fees to make the transfer of care outside of hospital possible.
- Governance and accountability. Complexities around the management of financial and clinical risk have slowed the progress of PBC, as PCTs have struggled to find the right mechanisms for holding GPs to account. Methods of coping with conflicts of interest – inherent in the role of GP as commissioner and provider – are only just emerging.
- Financial deficits. The presence of financial deficits on commissioning budgets in most PCTs has perhaps been the most important barrier, since this has either undermined the ability of a practice-based commissioner to have any realistic chance of making savings (the core incentive for participation) and/or meant that PCTs have been reluctant to allow savings to be retained locally if this compromised their overall financial position.
As a mechanism for clinical engagement to shift care out of hospitals and to lead service redesign, PBC has not fundamentally altered the power in commissioning relationships still dominated by large providers. The lack of progress has meant that GP enthusiasm for getting involved in PBC is on the wane, despite the fact that the majority (about 60-65%) still support PBC in general terms.(5)
Moreover, at present, PBC is best characterised as a part-time amateur sport pursued by innovative GPs rather than an approach that is embedded into the system. The big question is: can PBC evolve into a key lever for change?
What is needed to reinvigorate PBC?
In its current format, PBC is clearly not operating effectively. PBC lacks the vision, leadership, commitment, incentives and infrastructure required to make it look “professional”. “Reinvigorating” PBC requires more than a cosmetic exercise in policy renewal but a structured program that, as a minimum, would provide:
- A clearer policy vision for the future role and remit of PBC, replacing the current set of competing visions with a new consensus.
- Fully integrated as a part of the world class commissioning framework in order to demonstrate its strategic importance and contribution.
- Clear articulation of the respective roles and responsibilities of practice-based commissioners and PCTs.
- PCTs held accountable for the support they provide to practice-based commissioners.
- Clear arrangements for governance, accountability and performance management – including ways of resolving the conflict of interest within PBC.
- Proper resource and support for PBC to develop the capacity and skills of PCT managers and GP practices. Education, professional development and commissioning support functions – particularly on issues related to budget setting and timely data generation and analysis – need immediate investment.
- A mixed set of incentives to participate needs to be applied, combining the ability to make and utilise savings with local enhanced services (LES) payments, innovation funding, and organisational development support packages.
Removing these barriers is a huge challenge. It remains questionable whether PBC can really succeed without more fundamental change. A strong message from history is that GP engagement and rates of progress – in terms of services commissioned and provided – occurs where there is freedom to contract independently, albeit for a well-defined and limited range of primary and community care services.
The principal problem facing PBC is the “hybrid” nature of the scheme. PBC seeks to involve GPs in a voluntary commissioning “partnership” with PCTs that inevitably leads to differing perspectives, an unwillingness to “let go” of responsibility and control, and limited financial incentives for GPs to engage.
What is required – if you truly believe in PBC – is the devolution of “real” budgets and increased autonomy for making commissioning decisions. However, devolved budgets also raise significant questions on how strategic commissioning activities at a PCT can be effectively combined with local PBC priorities.
For example, if PBC is to sit as a key lever for change within the world class commissioning framework, this implies a requirement for PBCs to be engaged in both agendas. Moreover, since government policies are seeking to create a diversity of primary and community-based organisations that compete with each other for service contracts, devolving budgets to practice-based commissioners might risk undermining contestability and patient choice.
To meet these agendas, an alternative model would be for PCTs to tender with PBCs to deliver a specific service, or range of services, while simultaneously enabling these organisations to hold and deploy commissioning budgets in a risk-sharing arrangement. The PBC would then be free to provide services and/or to contract with other agencies (in effect, have the power to make or buy decisions) while the PCT could hold them to account for delivering on service redesign issues.
Holding budgetary responsibility would be the key to the arrangement, since bearing some or all of the risk would encourage the delivery agency to manage resources effectively. Organisations making savings would potentially benefit from being able to redeploy resources locally, and would be free to create their own set of incentives for the professionals working within them – using a “shareholder” arrangement, for example.
Such an idea was raised in the NHS Next Stage Review through the concept of Integrated Care Organisations (ICOs).(6) While some of the most innovative and advanced practice-based commissioners are employing risk-sharing arrangements, none of the subsequent 16 integrated care pilots are testing such a model – an opportunity lost.(7)
PBC reinvigoration policy
The government’s reinvigoration guidance – Clinical commissioning: our vision for practice-based commissioning – has gone part way to meeting the necessary reinvigoration agenda described above.(4) It provides a more clear articulation of how PBC fits with the wider world class commissioning strategy, making it clear that PCTs will be held to account for the support they provide. It reiterates a number of key “entitlements” – including management support, financial information, swift budget-setting and business case decision-making processes.
The guidance also implores PCTs to develop “compacts” (local agreements) that establish clear roles and responsibilities and systems of governance. A PBC Development Framework with some resources to pump-prime PBC and a best practice network are also promised.(4)
However, the central “hybrid” architecture of PBC remains unchanged. In spite of the evidence, therefore, policymakers continue to pin their hopes to a partnership model, where a shared culture of innovation and health improvement can be fostered as practice-based commissioners inform, influence and complement the strategic direction of the PCT.
Nonetheless, there is explicit recognition at the end of Clinical commissioning that the model recommended in this paper – ICOs taking on responsibility for a budget as well as providing care to local people – could be the next level to which PBC will aspire.
The future of PBC
The future of PBC is in the balance. Forcing PCTs to become more accountable for it will not, of itself, generate the critical mass of innovators and clinical leaders required. History tells us how problematic it has been to enfranchise GPs to take an active and innovative part within the health system, and PBC provides us with a classic case in point.
A sensible bet would be to argue that the future will provide us with a growing range of innovative approaches to PBC, some of which might make a fundamental contribution to service redesign for patients, but that progress will remain limited to a small cadre of innovators.
For practice managers, making a decision on whether to persevere – or begin to engage – with PBC will depend on the strength of local relationships with PCTs, the financial health of the local system, and the mix of support and incentives provided. However, given the reinvigoration agenda and the potential ability of PBC to start “afresh” by negotiating a new “compact” and demanding core “entitlements”, it’s probably a case of now or never.
It is also worth speculating how PBC might change under a Conservative government. Following announcements that they would hand GPs their own commissioning budgets à la fundholding, it will be the well-managed and risk-taking PBC consortia who are potentially most likely to be in a position to benefit in the future.
References
1. Goodwin N. GP Fundholding. In: Le Grand J, Mays N, Mulligan J-A, editors. Learning from the NHS Internal Market: a review of the evidence. London: King’s Fund; 1998. pp. 43-68.
2. Mays N, Wyke S, Malbon G, Goodwin N, editors. The Purchasing of Health Care by Primary Care Organisations: an evaluation and guide to future policy. Buckingham: Open University Press; 2001.
3. Curry N, Goodwin N, Naylor C, Robertson R. Practice-based commissioning: reinvigorate, replace or abandon? London: King’s Fund; 2008.
4. Department of Health. Clinical commissioning: our vision for practice-based commissioning. London: DH; 2009.
5. Department of Health. Practice-based commissioning GP practice survey. London: DH; 2009.
6. Department of Health. NHS Next Stage Review: Our Vision for Primary and Community Care. London: DH; 2008.
7. Department of Health. Launch of Program of Integrated Care Pilots. London: DH; 2009.
