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A history of commissioning
“Commissioning” is simply about buying services and in some sense has always existed in the NHS. It became a distinct “function” 20 years ago following the NHS and Community Care Act. The 1990 Act explicitly divided the purchasers of healthcare from the providers of healthcare and so the importance of good healthcare purchasing, or commissioning, was born.
Over the last 20 years commissioning has been tweaked by successive governments, and health secretaries, but it has endured various reforms and all formats have had the same principal aim: of buying the best care at the best cost. The first and best known form of GP commissioning was “fundholding”. Under this scheme GPs were given real budgets to buy elective and non-emergency care for their patients. They could also seek and create new services to apply competitive pressure to hospitals and ensure they were buying the best service at the best cost. GPs were incentivised to take part by keeping any financial gains they made by commissioning cheaper services. By 1994 practices had started grouping together into Total Purchasing Pilots, not dissimilar to the consortia now being discussed. However, fundholding was optional for GPs and fears that it was creating a postcode lottery between good commissioners, bad commissioners and non-commissioners led to it being abandoned by the in-coming Labour government in 1997. Evidence that fundholding improved care was also mixed. While there were some reports of local improvements, particularly around hospital admissions, there was little else to appease those objecting on the grounds of a two tier system it created. Following the demise of GP fundholding the commissioning function was first transferred to primary care groups and then to Primary Care Trusts (PCT). The exact number and make up of these varied over the following decade, but while GPs were given some involvement within these, central managers took responsibility from practices. However, in 2004, the government announced its new GP commissioning plan: Practice Based Commissioning (PBC). At the time there was some derision that this was a simple return to fundholding but the government sought to learn from that experience and made several adjustments. Firstly, GPs were not allowed to hold real budgets. The power remained with PCTs to actually commission services but they would hand practices “indicative budgets” which GPs could then use to alter spending, but the buck still stopped with the PCTs. Secondly, any profits made would then have to be reinvested in patient care so that GPs were not seen to be making large profits off the back of it, as they had under fundholding. It did, however, still cause some controversy as GPs invested in practices that they may otherwise have done from their own purse, effectively supplementing their income. And thirdly, although PBC remained voluntary, the Department of Health mandated that PCTs should ensure that every practice in their area was in a commissioning group and had been provided with an indicative budget. Similarly to fundholding, PBC has brought about some small local improvements, but the government struggled to engage GPs as it was still voluntary. In 2009 David Colin-Thome the Primary Care Tsar eventually and infamously described the policy as “a corpse not for resuscitation” The latest form of GP commissioning as envisaged by the Health and Social Care Bill, seeks to build on these previous models. By making the consortia compulsory and national, it seeks to avoid the lottery and inertia that afflicted fundholding and PBC respectively. While not all GPs will be intricately involved in running consortia, all will have some interest as part of a wider group. By completely removing PCTs it also puts the responsibility more squarely with GPs than fundholding or PBC ever did. The incentive for GP engagement at this stage is still slightly opaque, but they will be given per capita management budgets to run the scheme and backfill GP posts for any time taken out of practice. A supporter of the current plans would say that the latest round of GP commissioning finally has the guts to go where fundholding and PBC didn’t, and will mean that all GPs have a chance to genuinely improve patient care. A critic would say that it has gone too far and overburdens a clinical profession with management responsibility it is neither trained for nor wants. At Best GP commissioning will give patients a greater say in services through their GP and the ability to switch secondary provider will give GPs a route by which to directly control the quality of service they refer their patient to. It could reduce waiting times, improve quality of provision and make the NHS more locally responsive. At Worst GPs may find themselves out of depth and unable to effectively commission. They could find the dual role of purchaser and provider creates a conflict of interest and that they lose the trust of patients whose care they could be perceived as rationing. It could also undermine hospital stability as services are picked off and impact workforce training as certain procedures are relocated.
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