Posts Tagged ‘GP’
The “Liberative” Government’s health reforms started life with a light and permissive vision of GP commissioning. But now they are mired in confusion. What happened? In short, the new vision collided with the old. Last week the Health Select Committee sided firmly with the old vision, calling for Consortia to be renamed as Commissioning Authorities with formal governance structures and stakeholder representation.
New vision or old, everybody wants commissioning to be done well. But what does commissioning mean, and how should it change?
In the conventional vision, commissioning starts with the carefully-assessed healthcare needs of your local population. Then you compare this against the services actually provided. Inevitably, you find plenty of areas where needs are not being met at all, or where provision could be improved, or where there is over-provision and ineffectiveness. Starting with the biggest mismatches, you work with other stakeholders to design new and better pathways, and then you seek providers to deliver them (or work with existing providers to improve things).
Conventionally, you manage “your” providers through the annual contracting process. You estimate the amount of activity to be done, and then apply the tariff price (if there is one) or negotiate a price (if there isn’t). You manage quality using Key Performance Indicators (KPIs). If quality falls short or activity is at variance with the contract volumes, then you apply the remedies specified in the contract.
So far, so familiar. But this is all office-based activity. What are the chances of it making a real difference to patients?
You hope to reach a position where need and provision roughly match. But your experience shows that anything you measure in healthcare displays huge and unexplained variations; if you do find a match between need and provision, it is only by chance. And if you achieve a match today, then it probably won’t match tomorrow. So trying to match need with provision is going to be highly inexact at best.
0.5% of the population consumed over 20% of acute spend
Patients also show great variety even within a single pathway, and the sickest patients usually have multiple conditions. The harder you try to tailor a pathway to a particular condition, the more you find there are exceptions to the rule. Do these exceptions matter? Yes, because they are your most expensive patients. Data from one PCT shows that a mere 0.5 per cent of the catchment population (about 1,000 people) accounted for over 20 per cent of acute expenditure. So good judgement by GPs trumps good pathway specification when it comes to handling the sheer variety of patients presenting.
What about quality? You hope that quality and performance can be managed with KPIs and contractual sanctions. But “quality” is too rich a concept to be described in even the most comprehensive list of KPIs. The harder you try to specify everything, the more you lock yourself into the status quo. Moreover, anything that isn’t in the KPIs is simply driven out: the effort of monitoring everything else in the contract takes over. So quality needs to managed through dialogue, not specification, and the organised concerns of GPs are a better guide to quality than words in a contract.
Even activity – the crunchiest of numbers – is hard to control in the standard contract. You can try to limit elective activity if the waiting list isn’t rising. You can try to throttle cost by using activity caps and restrictions on “procedures of limited clinical effectiveness”. However, most contractual changes need to be implemented with the agreement of the provider (which may not be forthcoming), and in any case tactics such as banning procedures tend to be blunt and limited instruments that displace or defer the problem rather than solving it.
Finally, awarding contracts only to selected providers (especially if the contracts specify guaranteed volumes) involves saying “no” to other potential providers. The argument is that this helps to control expenditure, but again there is a lot of hoping going on: you hope that, by restricting the availability of providers, you will reduce demand. As Don Giovanni said in a different context:
Wer nur einer getreu ist,
Begeht ein Unrecht an den andern;
If I am faithful to one,
I am unfaithful to all the others;
So the old vision of commissioning falls short on a number of counts. How could a new vision improve on it?
In commissioning, as with everything else in healthcare, real life happens in the consulting room not in the office. So better commissioning needs to happen in the consulting room too: if individual GPs manage their referrals and patient pathways well, then quality and budgets will follow. So the Consortium should focus its attention “downwards” to practices, rather than “upwards” to the Commissioning Board or “across” to providers.
That way, the life of a commissioner no longer revolves around the annual contracting round or the enforcement of KPIs. Instead, it revolves around helping GPs manage value, by:
- monitoring and escalating quality concerns raised by GPs;
- providing a “bank manager” function to GPs;
- peer-reviewing GP referral patterns and pooling risk;
- providing back-office, scheduling, and financial services to GPs;
- calling for new and better services, and helping prospective providers with their market research;
- ensuring that GPs are aware of the services and drugs available to them.
This moves decisively away from the adversarial contract-driven approach of the past. But one major step needs to be taken to make it work, a step that is not taken in the Health and Social Care Bill. Consortia need to be able to enforce budgetary limits at practice level, which is something that politicians (understandably) have tended to shy away from.
However, there is nothing to prevent GPs from opting to accept practice-level budgetary limits within their Consortium, or even formalising this rule in their Consortium’s constitution. After all, many GPs are pretty fed up with having their referrals interfered with, and their choice of providers restricted from on high, whenever PCTs are struggling to achieve their statutory duties because they cannot control demand.
So GPs and their Consortia are faced with a choice: genuine freedom to refer within a limited budget that they control; or a continuation of the imposed and inconsistent restrictions that face them now. What will they do? Perhaps the best outcome would be for different Consortia to make different choices. That would truly test the two visions of commissioning.
No wonder GPs up and down the country are looking at commissioning with unease, if not dread. The current system wouldn’t suit them at all. But commissioning doesn’t need to be this way, and the door is standing open for a much more human and collaborative approach that plays to GPs’ skills as doctors.
So what’s wrong with the current system? In short, the adversarial contract-driven approach doesn’t work.
Every year the PCT and the local hospital sit down with a copy of the standard (and compulsory) NHS contract, and negotiate the activity and the Key Performance Indicators (KPIs). The contract is only signed after they have reached agreement on all the terms (or after the SHA arbitrator has imposed agreement on the warring parties). After the financial year begins, the PCT holds the hospital to account for any failures against the KPIs by applying the contractual sanctions. If the hospital is doing more activity than specified in the contract (called “overperforming”), complex terms are applied to work out how the excess should be paid for.
What effect does all this have on the delivery of healthcare?
When it comes to quality, all eyes are focused on the KPIs (and only the KPIs). Remember that these have to be agreed in advance by both parties, and the hospital has no interest in creating a rod for its own back. So, even though the KPIs make a very long list, they are only a tiny subset of everything that means “quality” in healthcare. Even when something is specified, the standard is pitched at acceptable rather than aspirational. The usual response to these shortcomings is to define more KPIs, to make them tougher, and to raise the sanctions. But that doesn’t fix the essential problem.
Activity is a problem too. Neither the PCT nor the hospital can predict the demand for healthcare accurately, so the activity specified in the contract always misses the mark. The complex clauses that deal with “overperformance” serve to weaken the link between activity and money. PCTs can berate hospitals for overperforming or having excessive waiting times, and hospitals can berate PCTs for failing to manage demand, but what can either party actually do about it? And even when they can do something, do they want to? Hospitals make good money from uncontrolled demand, and can even generate income by referring work to themselves and other hospitals without prior approval.
And that’s just the incumbent providers. Tendering for new providers is long and complicated, with lots of pitfalls that can scupper the entire process. When a commissioner eventually makes it to the end of the process, the moment has probably passed anyway, and even if it hasn’t you are still in the unhelpful world of adversarial contract-management.
How could things be better?
GPs are small-business owners, and the world of the small business is quite different from this. Firstly, you pay for everything you order, and you don’t pay for anything you don’t order; so everybody knows where they stand when it comes to money.
Secondly, if a supplier does anything to displease you with regard to quality, anything at all, you have a grown-up discussion after which the supplier either puts things right or risks losing future business; the relationship works best when it is co-operative not adversarial, and quality is driven up relentlessly by customer expectations.
Thirdly, you can switch suppliers any time you like, although it takes effort to do this; so suppliers are keen to retain your business, and you are reasonably keen to avoid having to switch.
Healthcare can be like this too, and the Any Willing Provider (AWP) model provides most of the framework. The biggest thing missing from the official process is some way for GPs unilaterally to stop paying for anything they don’t refer, and it would be helpful if the Department of Health could put this right.
Even if this isn’t fixed officially, once GPs are established with co-operative relationships in a competitive (or potentially competitive) environment, then local providers should quickly learn that their interests lie in going along with GPs’ aspirations; because if they don’t, then it won’t be long before their local GPs are looking for alternatives right across their service range. They won’t be slow to do so either; not just because they know their patients and want the best for them, but also because they are scientifically trained and more than capable of generating and analysing relevant information about the service they are receiving.
Ah, defenders of the status quo say, but this is just a race to the bottom: AWP providers will only have to pass the minimum CQC standards, drive down their prices, and all the GPs will start herding patients their way.
This view is mistaken.
From the provider side, we have already seen how it is the existing contractual process that drives down standards. And from the GP side, the argument is frankly insulting: it accuses GPs of being completely uninterested in quality.
What GPs are actually interested in, just like customers in any market, is value: quality and cost considered together. So GPs will happily pay for a significantly better service, even if it costs a little more, just as consumers in the high street are willing to pay extra for better food and more advanced personal stereos. (In fact the history of machines for playing music shows how the result can be vastly higher quality and vastly lower cost.)
GPs needn’t fear commissioning; they just need to find a way of doing it in a way that suits them. It will come naturally, once they realise it’s possible. The people who may struggle are the ex-PCT staff who are hoping to support the commissioning consortia; will they be able to switch mindset to the GPs’ way of thinking, or will the contract-driven habits prove too deep to unlearn?
In his blog, Paul Corrigan repeats a familiar and widely-held view of the NHS commissioning reforms:
The Government plans to bet the whole of the NHS on the belief that GPs can deliver a business model that can buy £60 billion of NHS health… it is to be hoped that GPs understand how to operate in a business this size. …they will need skills that can work businesses with a turnover of £200-300 million pounds – hundreds of times bigger than the normal GP practice.
Dramatic. Astonishing. And thankfully, nonsense.
Firstly, GP’s already “understand how to operate in a business this size”, i.e. the size of the NHS, because that’s where they work now.
GPs also know how to “buy £60 billion of NHS health” (or at least their share of it) because every referral is a purchase, and that’s how much the referrals add up to. Each purchase is decided by the GP; and they always have been, which is why PCTs (and Health Authorities, and District Health Authorities, and Area Health Authorities before them) could never control their budgets.
So if the world is not going to change overnight for those GPs who aren’t actively involved in consortia, what about those who are? Will they be running giant corporations? Hardly. Here are some examples of real “businesses with a turnover of £200-300 million pounds”:
- Bovis Homes (466 employees)
- Majestic Wine (800 employees)
- Photo-me International (1,485 employees)
- Oxford Instruments (1,531 employees)
Even those GPs who are running Consortia will not need “skills that can work” businesses like these. They won’t be operating, managing, or even supervising this value of care. Instead they’ll be commissioning it. Quite different.
So what skills will commissioning require?
We could look for an answer by turning to present-day PCTs. There exists a long and dreary list of all the things that PCTs (supposedly) do at the moment. But do they really “undertake service redesign at a health economy level”, or “manage the local provider market”, or even “provide effective support for carers”? And even if they set their minds to it, could they? The reality is that, no, they couldn’t. Many fine words are written, but they are unmatched by deeds. Back in the real world, providers carry on doing their own thing; many carers remain ineffectively supported. GP Consortia do not need to take on the burden of pretending to deliver all that, and I’ve never met a GP who would want to anyway.
Nevertheless, commissioning something as complex as healthcare is a delicate business, requiring a high level of specialist expertise and commitment. The commissioner does not need the very high level of specialist expertise possessed by the provider, but a high level of general training and experience is certainly needed in order to place orders intelligently. The commissioner needs to be able to evaluate the needs of each case carefully, and commission a level of healthcare that is proportionate to that.
Strip all the fancy language away, and you can see that this is what GPs do all the time. They are general practitioners after all; not specialised, like consultants, but highly trained and experienced nevertheless. They use their skill and judgement to decide whether and how to refer each patient on to secondary care. That referral is equivalent to placing an order: commissioning, in NHS parlance. Which is what they do already: being GPs, not some multi-gazillion pound Master of the Universe type thing.
Neither is it a harmless pastime to exaggerate the challenge facing GP commissioners. Yes, they will be taking on more than they do now; they will have a budget to manage within, after all. But there is no need to make the challenge bigger than it really is or it might scare even the able ones off.
The NHS Chief Executive’s round robin on the White Paper will disappoint anyone who spent the summer holidays hoping it would all go away. After many kind words to those facing the axe, he laid out the message loud and clear: devolution, devolution, devolution.
Most of the attention around the White Paper so far has focused on commissioning: the dramatic abolition of SHAs and PCTs, and putting GPs in charge. Debates have raged about GP incentives, and whether they will have the skills to do what PCTs do now.
But this lopsided attention is curious because GP commissioning is not where most of the change is going to come from, nor where a lot of the PCTs’ current expertise will be needed. The Chief Executive’s letter recognises this, calling for “particular attention locally” towards:
The proposed changes to the provider system, where I think the extent of the changes and the freedoms and opportunities to innovate are particularly significant;
A quick glance at the outside world shows that this must be correct. Who are the innovators who create the latest cars and phones? Not the customers who buy them, that’s for sure. It’s people at Toyota, Apple, and the rest who identify the gaps in the market, spot opportunities to innovate, and design and produce the latest new products. We, the consumers, merely choose whether or not to buy them.
So it will be in the NHS. Providers will innovate, GPs and patients will choose.
This is not to belittle the importance of GPs and patients; they are the customer, and the customer is king. Nor does it imply that a choice of providers must exist everywhere for everything; the fact that new providers could set up a better service will keep the incumbents on their toes.
But it does mean that GP Consortia should think twice before taking on everything their PCT does at the moment. If it helps them balance the books or refer to different providers, then fine. But if it’s heavy analysis around demographics or disease prevalence that’s on offer, then a polite shove towards the provider market might be more sensible.
A recent study has just fallen into my lap (under the Chatham House rule). It is the initial findings of a casenotes review of over 100 short-stay (zero- and one-day) emergency admissions at an English acute hospital.
For me the most interesting highlights of these short-stay admissions were:
- Only 33% were appropriate (and only 22% of those from A&E) under the AEP
- For 80%, the grade of doctor making the decision to admit was “unclear” or “not documented”
- 50% of admissions from A&E were in the last half-hour before the 4 hour target was reached
Given that short-stay emergency admissions are common and rising, this presents a huge opportunity to GP Commissioners. In the short term the combination of unclear records, inappropriate admissions, and the absence of previous GP involvement in the patient all point to opportunities to challenge the hospital’s claims for payment. In the longer term, it presents opportunities for GP triaging of A&E attenders, and the establishment of primary and community alternative pathways.
Isn’t that a bit rough on the hospital? Not really. Not just because the inappropriate admissions are, well, inappropriate. But also because there may be darker things going on underneath these headline figures.
The fact that half of admissions from A&E are made in a scramble, just before the 4 hour target is breached, ties in with national figures and offers a clue about why so many admissions are inappropriate. According to the Information Centre:
Of those patients discharged [from A&E] within the final 10 minutes of the 4 hour wait target, the highest proportion (64.7 per cent) were recorded as ‘Admitted / became a lodged patient’.
So late admissions and inappropriate admissions are linked together. Which raises an intriguing question: is the lack of documentation about the admitting doctor also part of the picture? With only minutes to go before the target is breached, perhaps doctors are in such a rush to admit that the notes are left unclear? Or worse, are some patients being admitted “administratively”, by a non-doctor, just to achieve the target (as is sometimes alleged by NHS staff on comment boards, e.g. here, here, and here)?
The problem at the moment is that hospitals are heavily incentivised to behave like this. Such compromise corrodes the soul. If GP Commissioners challenged payments on inappropriate admissions, so that they became a cost to the hospital instead a benefit, then the world could start to turn the right way up again.
The King’s Fund has just published a new report on referral management, and delivered a cold shower to the referral management centres that some PCTs have created to weed and redirect GP referrals. It concludes:
the greater the degree of intervention, the greater the likelihood that the referral management approach does not present value for money.
Or, as one triaging GP put it:
It gets back to individuals making decisions on other people’s decisions.
Not that everything is rosy in the world of GP referrals. When GPs were allowed to review their colleagues’ referral letters they were not shy about saying what they thought:
When we first started, some of the referrals were absolutely appalling, dreadful. Two lines, referrals of two lines, please see this patient with headaches, and we automatically rejected all of those…
I mean, I just couldn’t believe my eyes initially, the quality of referrals was just dire
Well, criticisms are always fun to read. But what did work? In the words of the King’s Fund:
A referral management strategy built around peer review and audit, supported by consultant feedback, with clear referral criteria and evidence-based guidelines is most likely to be both cost- and clinically-effective. …
Practice-based commissioning clusters and their successors, the GP commissioning consortia, are the obvious conduit and driver for peer review and audit.
In other words, don’t second-guess the referring GPs; but do work at a doctor-to-doctor level on improving their referral skills. This makes perfect sense. At the time of referral, nobody knows the patient’s condition better than the referring GP. If some GPs aren’t very good at referrals, then the problem is unlikely to be solved by inserting a layer of second-guessers (who have only the inadequate referral letters to base their decisions on). As the King’s Fund says:
any intervention to manage referrals cannot look at the referral in isolation but needs to understand the context in which it is being made
So full marks for the King’s Fund report, then? Very nearly. My slight disagreement is when they say:
any referral management strategy needs to include a robust means of managing the inherent risks at the point when clinical responsibility for a patient is handed over from one clinician to another (so-called clinical hand-offs)
I would argue that they accept the concept of the “clinical hand-off” too readily. Referrals should not be fire-and-forget, rather the GP should remain available as the patient’s advisor after the referral has been made. After all, patients must give their informed consent to every step of their treatment, and both the consultant and the GP have a role to play in informing them.
The White Paper was like diving into a British lake: a cold shock, a rush of blood, a feeling of disorientation, and yet all somehow very invigorating and healthy.
The SHAs are being abolished, and they will not be missed. I hope that now all the stories of bullying, extra-legal activity, and jobs for the boys will come out. The SHAs filled a gap in the organisational chart of top-down control, but in practice they neither insulated Ministers enough for Ministerial comfort, nor showed enough willingness to place Government policy above local issues to be genuinely useful to them. Soon they’ll be gone.
The abolition of PCTs has been deftly done. Now that so many PCTs are coterminous with local authorities, many people expected functions to transfer over. Health improvement is a natural transfer. So is the join with social care. Handing commissioning to GPs is also natural; in fact GPs have always done the commissioning because they refer the patients. What’s left? An untidy bag of statutory duties will need sorting out, but they are not enough to justify the PCTs’ existence. So off they go.
What emerges at local level is very different from the longstanding model of monopoly hospital toughing it out with monopsony commissioner. In its place we will have something more like a normal market, with many independent commissioners (the GP consortia) buying care from a much smaller number of hospitals. This is very much to be welcomed.
So what could go wrong? Plenty of course, and it will.
Quality will inevitably become much more variable around the country. So expect a lot of complaints about health inequalities and postcode lotteries, even as overall quality improves.
There also will be complaints about the funding formula, because as it is applied more locally, funding will become more variable. The strength of the assumptions being fed into the formula will start to look shakier on close local scrutiny, and the most likely result will be a simplification of the formula and a reduction in funding variation, amid loud complaints from the biggest losers.
Some hospitals will struggle to achieve Foundation status, and some Foundation trusts will flounder (as is happening already). As noted in an earlier post, many hospitals would work better if their monolithic structures were broken up, to separate the different clinical, operating and property functions within them. As with GP commissioning, this would be no more than a reflection of reality: consultants have always been clinically autonomous, and so it would make sense to rediscover their heritage and become organisationally and economically autonomous again too.
Some GPs will struggle with commissioning, especially in the early stages. But a penumbra of independent-sector services will emerge to provide the specialised services they need. This penumbra will not necessarily be big companies from overseas; their chances were better when they had big government to talk to. No, the GP consortia will be much smaller outfits, and will deal easily with boutique companies (like gooroo) providing very well-targeted expertise for the local situation, with each GP consortium remaining in control as customer.
The separation of GPs’ personal fortunes and their commissioning budgets will be crucial, and difficult. GPs will be establishing out-of-hospital services for conditions like diabetes, COPD, and cardiology, referring patients to those services, and profiting from providing them. It will appear that they are pocketing their commissioning budgets in the process, and there will be sufficient wriggle room in the application of the tariff to blunt protestations that they are simply competing on a level playing field. Handling this blurring of boundaries between commissioning and providing will probably be the commissioning regulator’s biggest challenge.
The regulators will face constant temptation to extend their powers and intervene more. Every scandal and every failure will bring calls for Ministers and the regulators to “do something”. These temptations to recreate SHA-style powers through the regulators will need to be firmly resisted if GP Commissioning is to flourish and providers are to become more responsive. The heavier the hand of regulation, the more everyone will look to the regulator instead of to the patient.
As the feelings of disorientation wear off, and as the detail of these changes becomes clearer, it will start to feel as if there are more problems than solutions in these changes. However, a decade from now, I think we will all look back and wonder how we ever tried to run the NHS as a management hierarchy, defying the reality that doctors were autonomous all the time.
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.)