NHS gooroo blog

Archive for May, 2010

Whether they want to be or not, GPs are commissioners. Every time they refer a patient, they are committing resources to them.

But not all GPs see themselves as commissioners. After all, isn’t commissioning a complex process of planning, analysing, monitoring, and contract management? PCTs employ whole departments to do that, so why would a GP want to take it on? And if they did, how could they do it well?

There are plenty of compelling reasons why things would be better if GPs (and other practice clinicians) did take a more active role in commissioning. After all, who else could do the job better? On the commissioning side, only they know the patient well enough and have the skill and knowledge to make the right clinical judgement.

When looking for ways to improve GP commissioning, the debate has tended to focus on incentives or, more narrowly, how money can be used to reward GPs for referring within a budget. But there is more to effective commissioning than just meeting a budget (clinical quality immediately springs to mind). And there is more to raising performance than financial reward; the three main factors being ability, motivation, and opportunity (the “AMO model“). So how can we use this broader approach to develop better GP commissioning?

Let’s start with ability, which is built of things like skill, reasoning and perception. We can’t easily improve all of these (improving skill and reasoning is a challenge), but we can improve perception because it depends on the information available to a GP.

A commissioning GP needs easily-accessible information that is up-to-date, accurate, and specific to their own referrals, so that they can monitor their referral spend and keep on top of it. In the past an information analyst would have been needed to crunch the numbers, but new web-based systems (like Mede) can now deliver digestible information and alerts from the SUS datasets directly to GPs.

GP commissioners also benefit from support from a real human, and this is where PCTs can provide a bank manager service: challenging overspends, spotting unusual activity on the account, and advising alternative courses of action.

Next: opportunity. To what extent do GPs have the clinical discretion to change referral patterns and adapt to budgetary constraints? The answer has got to be “some discretion”, at least, simply because clinical need is a grey area in which human judgements must be made. Beyond that, we are into the practicalities: are alternative pathways available?

Obviously an available pathway must physically exist as a service. Not only that, but GPs need to be able to refer to it, so there must be a contract in place with the PCT. Also, it is only worth using an alternative pathway if it provides suitable clinical quality (so GPs need the assurance of good clinical governance processes) at a lower cost (so the price needs to be directly comparable with the on-tariff alternative). PCTs can help here by providing pathway management support to make GPs aware of the alternative pathways available and help them weigh their merits.

Finally let’s look at motivation. Certainly money into the GP’s or practice’s bank account is going to motivate, and this can be formulated in more ways than the Fundholding approach of simply allowing practices to “keep the change” if they come in under budget. For instance, one or more budgetary ceilings can be set, and practices awarded a modest percentage of the underspend against each ceiling. Non-financial forms of encouragement include status (a consortium leadership, a new pathway directorship, a thought leader), and simple recognition and praise.

As well as encouraging GP commissioners, the PCT needs to be careful not to discourage them with upsets like frequent rule changes, unfair rewards, or failing to support GPs in disputes with providers.

So we have lots of possibilities for improving GP commissioning: information systems and bank-manager support to improve ability; financial and non-financial rewards to improve motivation; and alternative pathways with attractive contracts and assured quality to improve opportunity.

Would I prescribe any particular combination of all these things? No, because every situation is different, and nobody knows exactly what will work best in each case. It would be much better for PCTs and GPs to invent their own approaches together, trying things out, making mistakes, and constantly improving. Partly because that is a good way to solve a complex problem. But also because the satisfaction of problem solved and a job well done is itself a powerful motivator.

Every year the NHS plans its future activity in great detail. And things never turn out that way. Why? And what should change?

Each year, information professionals in Trusts and PCTs devote enormous effort to the annual planning round. Activity for the coming year is described in intense detail, broken down by HRG, by calendar month, by specialty, between electives and non-electives of various kinds, and not least between each separate commissioner and provider.

Every year, the plans fail to anticipate reality. The finer the detail, the more inaccurate those details are. It’s nobody’s fault, because the demand for healthcare is largely random. But shouldn’t we be wondering what is the point of all this planning? And worrying, perhaps, whether any attempt to stick to such plans might be suppressing innovation and improved pathways of care?

This is an example of a point raised in an earlier post, which contrasted the conventional NHS conception of “strategy” (a kind of long-range plan) with Carl von Clausewitz’s conception of strategy as a way of responding to events in order to achieve an objective. So let’s start with the objective, and then look at the theories that might guide our responses to events.

The objective is fairly straightforward: for each Trust and PCT to balance its books at the end of the year, by planning activity to fit the budget available.

Simple as that. We don’t really care about the activity for Minor Ear Procedures in June, even though we may specify it. And the process we use to draw up our plans reflects our real priorities. Nobody picks through the detail, number by number, estimating from first principles exactly what each number should be. Instead we start with whatever happened last year, and apply some broad assumptions about demand, the tariff, shifts to daycase and outpatient settings, and some particular adjustments if we know that certain pathways are going to change. This is a top-down planning process, disguised in its presentation as being bottom-up. Perhaps, as expert providers of top-down planning services, we at Gooroo Ltd should hesitate to say so, but this is really not the best way to go about it.

A genuine bottom-up planning process would start by defining the bottom. HRGs? Months? I don’t think so. How about GPs? That’s more like it. If our theories about how to achieve financial balance include giving GPs greater control over finances, then the plans should be directly relevant to them. So commissioning GPs need to know in real time how their overall referrals and costs compare with their indicative budgets and with last year. If a particular area is ballooning out, they need to be able to spot it and address it. If an individual patient ended up costing many times more than expected, they need to spot that and challenge it. If a waiting list backlog needs tackling, then activity will need to exceed referrals temporarily. Note that this is not the same as increasing the level of planning detail; it’s about defining the objective at the right level and then being able to monitor and respond as time goes by.

If that is the intention, then where does that leave our planning process?

Firstly, it unhooks the commissioner plans from the provider plans. They do not need to reconcile. Trusts would plan in the same way as any market-driven business: anticipating likely trends and competitive effects, and looking for areas to expand or contract, to break into or withdraw from. If they cannot attract the referrals they were hoping for, then they need to adapt. They cannot expect any plans that commissioners may (or may not) draw up to translate automatically into referrals or income. In short, trusts would plan less and respond more.

Secondly, it pushes genuine monitoring and planning to GPs. GPs need to be equipped to do this, and given an interest in doing so (a big subject, and best left for discussion in another post), but they are certainly capable of doing it well. The role of PCTs in acute commissioning is then to act as a kind of bank manager, supporting GPs in setting, monitoring and balancing their budgets, providing the IT systems and central analysis they need, and helping to administer risk pooling arrangements.

That is very different from the current planning process. But then again, it might turn out to have its uses, even beyond the early days of each new financial year.

Who can manage the demand for healthcare? GPs can. But who else?

Most of the NHS’s work starts with a referral from a GP. That simple fact leads to GPs being described as the “gatekeepers of the NHS” and asked, one way or another, to take responsibility for managing (i.e. restraining) demand and solving all the NHS’s financial woes.

As financial pressures grow, the calls on GPs to restrain referrals and costs will become louder. But how much should GPs take on? Could the temptations to enrich themselves in unethical ways become too strong? And is there a more interesting way to achieve the same objectives, that involve patients and other players more?

Let’s start from where we are now, with GPs having some limited ability to influence the patient pathway and its cost. What makes it limited? Because referrals are fire-and-forget: when a patient has been referred to a consultant, the consultant “owns” the patient, and the consultant has the discretion to make tertiary referrals, keep the patient in bed, prescribe drugs… in short to spend the commissioner’s money on the patient largely as the consultant sees fit (and often to the advantage of the Trust that employs the consultant).

Certainly there are good clinical reasons for this arrangement. But in no other industry would a customer let its suppliers order work from themselves at the customer’s expense.

GPs do sometimes have powers to interrupt the patient pathway using Prior Approval schemes. These can allow commissioners to withhold payment for work that was not approved in advance, either explicitly or by being part of an approved pathway. But Prior Approval schemes have to be agreed with the provider before they can be written into the contract, and a cash-strapped Trust may not welcome a potential loss of valuable excess bed day payments.

So should GPs be given power over the whole patient pathway from end to end, to interrupt consultant-led care, and pull patients out of acute hospitals for transfer to lower-cost providers? Not so fast. Apart from the good clinical reasons mentioned above, it would generate great resistance and ill-will between GPs and consultants: the very people who most need to work co-operatively together if financial control is to be devolved successfully to the front line. So is this line of thinking all a dead end?

No, wait. We’re forgetting somebody. I don’t mean to be unhelpful, but what about the patient?*

The patient (or, if incapable, the patient’s representative) needs to give informed consent at every step along the pathway. Patients are not usually familiar with all the consultants available, their special interests, or the waiting times, infection risks, and other quality standards at each provider. So they need to be informed by healthcare professionals whose judgement they can trust. That certainly includes their consultant, if they are under a consultant’s care. But it surely also includes their GP, no matter whose care they are under?

Now an answer is starting to emerge. If GPs were more available to inform and advise patients at all stages of the patient pathway, even when they are lying in a hospital bed, then patients could manage their own pathways more effectively. Most would choose lower-intensity care closer to home if they could, which aligns well with the preferences of their GP when finances are also considered. It also neatly blunts the potential for a (hypothetical) unscrupulous GP to make money simply by delaying referral, as the patient would be unlikely to agree, and hospital consultants would be involved in the clinical governance process for reviewing the pathways they are using.

This means more work for GPs, and that would cost money of course. But who could be better placed to judge the merits of that trade-off, than the commissioning GPs themselves? Putting patients in control of their own pathways, with guidance at every step from their GPs, is an idea worth trying.

*(“What about the patient?” is a fun game to play in NHS management meetings. If the discussion starts veering off in a direction you don’t like, lean forward and very earnestly ask “what about the patient?”. It stops the discussion stone dead, everybody takes turns to make politically-correct statements about patients, and nobody will have the courage to get back on-topic. Warning: doesn’t work against practising clinicians.)

The General Election is upon us, and on Friday this country may have a new Government. What should the next Health Secretary do with the NHS? Rob Findlay takes a look at some of the options.

“We won’t cut the NHS”, say politicians of all parties. But after years of rising budgets, everyone knows the coming financial squeeze is going to be painful. So what should the new Health Secretary do to balance the books, without hitting quality and access at the same time?

The main thing the new Health Secretary will need to get a grip on is demand: the big issue for PCTs and Trusts alike. PCTs cannot put a cap on GP referrals (and rightly so). But in the long run PCTs nevertheless have to pay for the all patients that GPs refer, whether they can afford to or not. This dilemma cannot be resolved by the PCTs alone and, as the finances dry up, some will find that they cannot balance the books.

Demand squeezes the Trusts too. Even though the tariff entitles Trusts to payment for the work they do, the NHS contract does not give them freedom to do unlimited amounts of it in any given year. If activity falls short of demand, then all the shortfall ends up on the waiting list and raises pressure on waiting times. Even if the new Health Secretary is minded to go easy on targets, they are unlikely (and would be unwise) to let go of waiting times completely. That means that Trusts are in the demand squeeze as well.

If Trusts cannot control demand, and PCTs cannot control demand, then who can? Conventionally the answer is: the GPs who refer the patients in the first place. But this gives rise to new problems, such as: how do you stop a (hypothetical) unscrupulous GP from lining his or her pockets by simple dodges like delaying Edith’s hip operation or cutting her prescriptions? That was the big objection to GP Fundholding back in the 1980s, and is likely to be the objection again now. I suggest that there are more interesting ways of looking at this problem, which include players other than GPs (notably patients themselves), and that the problems are indeed soluble. But that is a longer discussion that will need to wait for a future post.

For an organisation that is fundamentally about people, the NHS has an unhealthy obsession with buildings and organisational charts. This needs to change. Buildings and organisations are merely services that help front-line professionals care for and advise their patients. In that spirit, acute provision should move closer to the front line, as hospital consultants rediscover their heritage and become consultants again in the true sense. With theatre time costing something like £25 per minute, why do operating sessions so often start half an hour late, and would that still happen if the theatre was being hired out of the consultants’ own pockets? It is hard to deny that there is scope for improvement here, and the concerns about improper self-enrichment are far less pressing because the incentives would be the same as for any existing independent-sector provider. Most of the obstacles that used to stand in the way of more independent consultants have already been removed, including that of the NHS pension, so all that is now needed is a favourable political climate.

All this devolution to the front line would be held back, however, if top-down initiatives were not reined in. There are some obvious action points here: bringing the World Class Commissioning movement to a dignified close, decentralising decisions on IT investment and innovation, and refocusing SHAs into a more supporting rather than controlling role. Likewise the vast numbers of centrally-directed targets should be devolved to become local performance standards, so long as this process happens no faster than the devolution of financial control to the front line. I would make an exception of the 18-week target, however, and retain that as a national requirement in order to focus attention onto demand and pathway management.

Finally, the new Health Secretary should lead the NHS in taking a different view about the meaning of the word strategy. The NHS conventionally uses “strategy” to mean a kind of long-range plan, with all the objectives, the interactions between different players, and the intermediate steps mapped out and described in detail. Such strategies change frequently, which in itself suggests that this approach is not helpful. Instead (following General Carl von Clausewitz) “strategy” should be thought of as comprising: the overall objectives (e.g. better, cheaper healthcare); theories about how those objectives can be achieved (e.g. by devolving financial control to front-line professionals); and then those theories are used to guide both deliberate action and (more usually) the many and continuing daily responses to unforeseeable events. Again, this is a theme we will pick up in future posts, and it applies particularly to the planning process.