Feature

Really working for patients

GP commissioning goes beyond fundholding in its ability to secure good health care for all and address public health issues, argues Ron Singer

Much has been written about GP fundholding, but less about GP commissioning which must now be understood, mary care level function as a ‘commissioning process’ focused on the individual patient. They are well-paid sorters of health (and social) care problems. Someone presenting with a cough may be offered advice (‘It’s only a viral infection’), treatment, investigation (‘It could be your heart’), or admission (‘You may have pneumonia’). This is a common process for all GPs.

Beyond the level of the individual patient, this process can take two routes. Fundholders arrange ‘provider’ contracts only for their practice’s patients, often in isolation from neighbouring practices. Other GPs have developed a system for influencing their health authority’s commissioning process by forming GP commissioning groups. These groups, often representing 200 GPs and therefore 400,000 people, focus on the needs of all patients not just the patients of their own, or other GPs’, lists. They think in terms of the health needs of the local population and co-operate on behalf of all patients to secure the best services for the whole population.

The decision about which hospital to contract with therefore differs according to the status of the patient’s GP. Fundholders, acting only for patients on their list (say 10,000 people), will be influenced by the best deal they can achieve with local hospitals. These deals will often mean faster treatment for their patients and hence slower treatment for others-‘two tierism’. Unless fundholders can achieve such an advantage over neighbouring practices there is no point in fundholding in the first place.

Health authorities too will be influenced by financial factors but will be commissioning all services for non-fundholding GPs, all services for people not registered with a GP and services not covered by the fundholding scheme. (About 70 per cent of services needed by standard fundholders’ patients and about 95 per cent of services for community fundholders are outside the fundholding scheme.)

Fundholding has attracted less than 50 per cent of GPs in six years, despite campaigning, bribes and even threats by government and some local managers. In addition, frequent polls have found that a majority of fundholders are, in principle, against the scheme. They often joined to prevent their patients being disadvantaged by neighbouring fundholding practices, so-called ‘reluctant fundholders’.

Fundholding can be seen as the GP end of the competitive, internal market and GP commissioning as an attempt to plan services in spite of market imperatives. This commissioning ethos better fits the way GPs and primary care teams feel about the provision of healthcare. The simple concept of GP representatives working together with their health authorities and local hospitals, with their practice colleagues and the wider primary care team, is in keeping with the core tenets of the NHS: the best healthcare for all regardless of gender, race, need, or the practice with which they happen to be registered.

How does GP commissioning work and how does it answer its critics? At its best, commissioning analyses an issue and explores all the available local resources that could tackle it. This process can range across health and social services, education, environmental health, the police, roads and housing design. It is a positive concept: not anti-fundholding, not non-fundholder but GP (or indeed community nurse) commissioner.

Commissioning groups are a natural way for healthcare workers (not just GPs) to co-operate and research local issues, and design strategies and programmes to meet those problems. They are large enough to aid the strategic planning of services but flexible enough to reflect differing local needs because they are based on small practice groupings. It is a model that addresses public health issues (such as inequalities in health)-something that fundholding was not designed to do and cannot be adapted to do.

There is currently information on 71 such groups, representing 25 per cent of the population (14 million people) and incorporating over 7,000 GPs, (with a further 30 or so other groups in existence.) With the launch of its own association last year - the National Association of Commissioning GPs-GP commissioners have argued their case to the Department of Health, politicians, health economists and other GPs, with great success-a notable exception being the previous health secretary Virginia Bottomley. Stephen Dorrell apparently has a more open mind.

Because of the spontaneous development of commissioning groups their structure varies, but they operate in a broadly similar manner. Typically, a commissioning group covers either the whole health agency (formerly health authority) area, or a part of the area-a locality-hence ‘locality commissioning’. Membership is democratically based and the group will have its own meetings as well as those with senior managers.

Unlike fundholding, commissioning GPs still receive little or no payment for their involvement and yet they are some of the most enthusiastic GPs, working in some of the best practices in their areas (‘first wave non-fundholders’).

An NACGP survey of all groups showed that the most any group received was £73,000, the same as would have been paid to two fundholding practices. Yet this is a group representing 500,000 people and 267 GPs. The money is there. If the total paid out in management fees alone to fundholders were to be split between commissioning groups , each group would receive £500,000.

Critics of GP commissioning say that fundholding has proved its worth and that GP commissioning cannot work because it does not actually control a budget. Yet evaluation of fundholding is incomplete. Latest research on fundholders’ drugs budgets shows that the early cost savings have not been sustained. Also, evaluations have never been made (or indeed allowed) comparing fundholding with the work of the best commissioning groups.

Groups have had their successes: the reorganisation of mental health services in Bristol; infertility services in Enfield and Haringey; and effective prescribing in Nottingham. Next year the group which I chair will review, with the health authority, neurology, orthopaedics and urology services. We also hope to look at out-of-hours cover from a commissioning point of view. Instead of just looking at the GP side, we will include the three local A&E departments, the role of GPs and nurse practitioners working with them, and develop a mini-emergency bed service for the area.

We are beginning to learn what commissioning groups can achieve with little or no money. We can only guess at what could be achieved if they were supported as fundholding has been.

Would fundholders buy such a commissioning framework? Judging from polls of fundholders about 70 per cent would without even arguing. The other 30 per cent may take a little friendly persuasion. Of the 71 recorded commissioning groups, nearly half have formal links with their local fundholders. Leading fundholders are realising that there is more that unites GPs than divides us as fundholder or non-fundholder.

Also, the evolution of fundholding into ‘multi-funds’ (groups of fundholders working together) and ‘total purchasing’ schemes (groups of fundholders buying all their patients’ health services) means that more GPs, fundholders or not, are now working together in groups, so reducing the competitive element that was to drive the NHS ‘reforms’.

Given the huge emphasis on fundholding, the development of such a committed, innovative and successful model for health commissioning should not have occurred. The government’s attitude is to pretend that GP commissioning never happened.

The Labour Party has asserted its opposition to fundholding and support for a ‘commissioning framework’ which would build on GP commissioning groups and the expertise that some fundholders have accumulated. A variety of ways to incorporate fundholding into a wider commissioning structure exist.¹

Meanwhile GP commissioners are refining the model because it allows them to continue to advise individual patients on their health needs without having one eye on the practice budget, while also providing a route to influence healthcare provision for the whole local population.

Patients, GP commissioners, including fundholders, primary care team colleagues, managers and, dare I say, politicians, have much to gain from a commissioning framework that does lead the NHS from primary care (not just from general practice), does address need and inequalities in health (not just for some but for all) and does take the wider, public health view of health service planning and delivery-the very concepts that make the NHS such an envied, cost-effective and truly national service.