Feature

All talk, no action?

David Wainwright warns that without some template for how to go about commissioning, primary care groups risk substituting developing the commissioning mechanism for the activity itself

New Labour’s ‘new NHS’, in which GPs and community nurses join forces in Primary Care Groups to lead service development and commissioning, was finally born at the start of April after a fevered gestation.

But despite the title of the white paper proposing the reforms—The New NHS: modern, dependable—entirely ‘new’ forms of public administration are rare. Those charged with implementing the latest initiative might profit from paying close attention to earlier experiments in delegated decision-making.

Fundholding is the most obvious and research now exists on its strengths and weaknesses. Although fundholding evolved into a series of different models (varying in their degree of budgetary delegation), fundholders were left in no doubt about the fundamental principles of the commissioning mechanism.

The same cannot be said of PCGs. Although the white paper identified four models of PCG responsibility, ranging from health authority advisory board to total budget-holding trust, there was no blueprint for their form and function. Instead, it was hoped that PCGs would evolve from existing commissioning models in response to local circumstances.

This open-ended approach mirrors that of the Conservative government’s earlier attempt to implement primary care-led commissioning alongside fundholding. As with Labour’s PCGs, there was no template for development: health authorities were expected to develop commissioning models in consultation with local stakeholders.

This will sound familiar to those charged with deciding how the new PCGs should work and the lessons learned from primary care-led commissioning could be instructive, in particular the obstacles that could impede PCG development.

East Kent was among the few health authorities to pilot primary care-led commissioning, establishing three pilots which were evaluated by the Centre for Health Services Studies.

What we found from our interviews (see box) was that the demands commissioning activity would make on already over-burdened GPs was a major issue, plus the usual concerns about remuneration and provision of locum cover.

Interestingly, there were differing views about the optimum amount of time a GP should spend on commissioning. Some interviewees suggested that it was a full-time job: ‘I don’t think general practitioners can do it on a part-time basis, if you think you can do a full surgery, and then just come for odd meetings. There’s a lot of work, you’ve got to think issues through… so we are talking about a GP who will be spending half-time, or even full-time, completely committed to that purpose.’

Conversely, a health authority manager noted that the rationale for involving GPs in the commissioning process was precisely because they had hands-on experience of patient care: ‘If you don’t have practising GPs I think you’re losing the essence of what we want the GP there for. I don’t see any point in saying ‘how about not being a GP anymore and being a medical adviser’, because that’s losing what we want the GP there for, which is contact with the patient, to know what the patient needs.’

This trade-off between the time GPs invest in commissioning activity and maintaining patient contact will need to be consciously addressed by the PCG boards.

GPs’ competence as commissioners was also raised, and familiar arguments about the need for management training were rehearsed. It was suggested that GPs might lack a district-wide perspective and the expertise to commission some services: ‘[GPs] are not enough aware of the totality of problems across East Kent. They know what their particular patients want, but there are some things that they don’t know very much about.’

Arguably, the need to commission within the parameters of an health improvment programme (HImP) will ensure that PCGs do not lapse into myopic localism, but the need for GPs to acquire a broader perspective is essential to them becoming effective commissioners.

Our evaluation revealed other anxieties about cultural change. Under primary care-led commissioning, HA managers would be working in closer proximity to practitioners and patients, witnessing first hand the effects of their commissioning activity.

One HA director said: ‘I’ll have less control of the staff, because they will be relating to whichever groups they support as much, if not more, than they will to me.

‘It will be a case of me ensuring that they maintain their skills and don’t go native on us, just keeping in touch with what they’re doing and making sure that nothing’s going to happen that will sink the health authority.’

Despite some guidance, the question of managerial accountability in PCGs has not yet been fully resolved.

The extent to which GP involvement in financial decision-making would damage the doctor/patient relationship also posed a dilemma. On one hand, control over budgets was seen as an essential lever of change, ‘one GP with a cheque book is worth half a dozen on committees’. On the other, it was recognised that this would lead to GP involvement in rationing or service prioritisation: ‘I have had one GP say to me that he’s happy to spend money but he will resign as soon as he’s asked to make a saving. He will not sit in judgement on cutbacks because he doesn’t feel he can then sit in front of his patients.

‘He’s happy to sit there while we spend our money but he will not join in when we say, ‘we have to save £100,000 this year, where are we going to do it?’ At that point he will withdraw.’

This is an old concern dating back to the beginnings of fundholding. But a different slant was revealed by one GP who said that although he was not prepared to make rationing decisions at the level of the individual patient, he would be willing to participate in collective decisions on priorities by the commissioning team, as this would enable him to say to patients: ‘I’m terribly sorry, I would like you to have your tattoos removed, but you can’t because that service isn’t available in this locality.’

This suggests that PCGs (particularly given the inclusion of lay representatives) might enable GPs to participate in rationing decisions with a clear conscience – effectively providing the moral sleeping pill the profession has sought for so long.

A year into the East Kent pilot projects there was disappointment about lack of progress. The pilots had wrestled with the issues outlined above and conducted detailed information analysis, but they had not agreed a formula for budget delegation or significantly influenced commissioning.

Insufficient information technology was advanced as one reason for the inertia – a claim also made in advance for the new PCGs. It seems to have become the first law of health policy that the success of any new commissioning model depends upon ever greater proliferation of computers.

Yet, as one HA manager noted, extensive information analysis can hinder decision-making: ‘They spend lots of time doing health needs analysis, which is some sort of holy grail. It’s useful to have some comparative information, but there are some good core scan methods of working out what you want to focus on.

‘This widespread gold panning exercise is based upon the assumption that if we do health needs analysis something will shine out and we will be able to say ‘ah, that’s what we want to do’. Nine times out of ten you will come up with a gold nugget and then say “we already knew that”.’

It is a truism that endless information analysis can usurp decision-making but is it the cause of the malaise or merely a symptom? Perhaps it was the absence of a prescribed commissioning model with clearly stated parameters, roles and responsibilities that undermined the pilot commissioning groups’ decision-making competence.

As the NHS Executive’s planning director wrote in 1996, when asked what primary care-led commissioning meant: ‘My first response is to ask, what do you think it means?’

Logically it would be ironic to implement the policy of a primary care-led NHS by imposing a top-down model. But such logic confuses the activity of commissioning with developing an effective mechanism for doing so.

It may be appropriate for primary care workers to lead the commissioning of services but, given that few of them are experts in public administration, it is surely a mistake to expect them also to design a new commissioning model. This is particularly the case when the process is fraught with tensions between central planning and local incrementalism, and between managerial and clinical imperatives.

Faced with such tensions, and in the absence of detailed guidance, it is hardly surprising that those responsible for implementing primary care-led commissioning chose focus on the minutiae of information analysis, rather than the more risky business of actual decision-making.

No one would wish to see a return to the heavy-handed manner in which the 1990 NHS reforms were imposed. And the government’s injunction that PCGs should evolve from existing commissioning models in response to local circumstances and consultation is clearly intended as a pragmatic way forward.

But the lesson from the East Kent pilots is that to become effective decision-making entities, PCGs must be provided with a detailed template for the commissioning mechanism. Without such guidance, PCGs may spend more time trying to resolve organisational tensions than on the pressing task of building a new NHS.