Posts Tagged ‘Strategy’
The Department of Health’s draft Mandate to the new NHS Commissioning Board was published last week, and it’s bad news for anybody hoping for a bit of common sense on the 18-week waiting times targets. All three targets are being retained: that’s one target telling hospitals to treat their long-waiting patients, and two targets punishing them if they do.
The good news is that this is a consultation draft, so you have until 26th September to tell the Department of Health why they should reconsider. As usual, with government consultations, you have to find a way to fit your comments into a pre-defined set of strangely-tangential questions, and in this case the one to use is question 3: “Are the objectives right?”.
I am sure that staff in many Trusts will be able to provide the Department with plenty of examples from their own experience of how the offending targets have distorted patient care, confused and misled stakeholders on the waiting times position, and resulted in unfair criticism and financial penalties, when all they are trying to do is the right thing for patients.
Here is the response I am submitting:
Question 3. Are the objectives right? Could they be simplified and/or reduced in number; are there objectives missing? Do they reflect the over-arching goals of NHS commissioning?
Objective 10 specifically mentions three service performance standards for referral-to-treatment (RTT) waiting times. An NHS Trust with few long-waiters will achieve all three performance standards, and one with many long-waiters will not. However that does not mean they are all good standards to use, and the use of all three is already having unintended consequences for patients in those parts of the NHS where a backlog of long-waiters has built up.
Specifically, two of the performance standards (that 90% of admitted and 95% of non-admitted patients must start treatment within a maximum of 18 weeks from referral) are often detrimental to waiting times performance, undermine the ability of the NHS to deliver the NHS Constitution right to treatment within 18 weeks, and are unfair both to patients and to NHS Trusts; these two standards should be omitted. The third RTT standard (that 92% of incomplete pathways should have been waiting no more than 18 weeks from referral) should be retained.
The following example illustrates the point.
Trust A has developed a backlog of patients on its waiting list who have already waited over 18 weeks. The Trust does not want to have a backlog, and notes that the NHS Constitution right to treatment within 18 weeks, the incomplete pathways performance standard, the accepted principle that patients with similar clinical priority should broadly be treated on a first-come-first-served basis, and the wishes of clinicians and managers alike, all point towards a clear and simple solution: treat the over-18-week waiters and thereby clear the backlog.
However Trust A is restricted from doing so by the admitted patients performance standard, which stipulates that 90% of admitted patients must be selected from those who have waited less than 18 weeks. (The performance standard for non-admitted patients has exactly the same effect, though in practice it is less likely to be the stumbling block.)
The admitted patients performance standard has a number of effects:
1) In order to clear 100 long-waiting patients who have already breached 18 weeks, the Trust must at the same time admit 900 short-waiting patients whether their clinical priority justifies it or not (and in most cases it will not). This queue-jumping is unfair to the long-waiting patients.
2) This queue-jumping also pushes up maximum waiting times (as queue-jumping does in any queue) thereby making the long-wait backlog worse than it would have been without the queue-jumping. The number of over-18-week waiters will therefore be much higher than it would have been, if the Trust had been allowed to treat non-urgent patients in date order. This undermines the NHS Constitution right to treatment within 18 weeks.
3) Put another way, the Trust is only able to clear the backlog slowly, because it is only allowed to devote 10% of its activity to the long-waiting backlog. If this restriction were lifted, it could devote all its non-urgent capacity to the backlog (typically between 50% and 95% of activity depending on the number of urgent patients in the casemix) and clear it much more quickly.
4) The Trust Board’s monthly Performance Report monitors all three performance standards, but a majority of Board members have a limited understanding of how the standards act in opposition to each other. This leads to poorer monitoring and decision-making than if just one performance standard, whose effect is intuitive, were monitored.
5) Statistics are collected and published nationally based on all three performance standards, which leads to misunderstandings about the NHS’s waiting times performance by the general public, journalists, and politicians. Such misunderstandings have in the past reached the highest level: exchanges between the Prime Minister and Leader of the Opposition at Prime Minister’s Questions have on occasion assumed that an increase in the number of long-waiters being treated is a bad thing, when in fact it resulted in a reduction in the number of long-waiters still waiting which is a good thing.
In contrast to the admitted and non-admitted performance standards, the newer standard (that 92% of patients on incomplete pathways should have been waiting no more than 18 weeks from referral) does not similarly frustrate good waiting list management, and should therefore be retained.
It may be that the admitted and non-admitted performance standards were included in Objective 10 because they are referred to in directions 2 and 6 of The Primary Care Trusts and Strategic Health Authorities (Waiting Times) Directions 2010, which were intended to support the 18 week rights in the NHS Constitution. For the reasons given above they are poor instruments for delivering that intention, and the directions should therefore be amended to omit reference to the admitted and non-admitted performance standards, and refer instead to the 92% incomplete pathways standard.
What on earth is going on with the Government’s referral-to-treatment waiting times targets?
In the last few weeks we have heard great things from them, showing that they now understand the problems created by the current target regime and want to move forwards. For instance the new Operating Framework says:
The operational standards of 90 per cent for admitted and 95 per cent for non-admitted completed waits as set out in the NHS Constitution remain. In order to sustain the delivery of these standards, trusts will need to ensure that 92 per cent of patients on an incomplete pathway should have been waiting no more than 18 weeks. The referral to treatment (RTT) operational standards should be achieved in each specialty by every organisation and this will be monitored monthly.
Operating Framework 2012/13, para 2.31
The new target is very welcome and in a perfect world it would have completely replaced the old targets (which punish Trusts for treating long-waiting patients). But abandoning the old targets would have required amendments to legislation, and invited political criticism that the Government was letting go of waiting times, so it isn’t entirely surprising that they have been retained.
This new, better direction of travel was reinforced in the latest edition of The Quarter. It said:
In addition to sustaining and improving performance against the NHS Constitution operational standards, the NHS must also ensure that those still waiting longer than 18 weeks are treated as quickly as possible. As set out in the NHS Operating Framework for 2012/13, from next year trusts will need to ensure that 92 percent of patients still waiting for treatment (also known as incomplete pathways) have been waiting no more than 18 weeks. Therefore, the NHS needs to take action to treat patients still waiting over 18 weeks after referral, for reasons other than choice or clinical exception.
In particular some trusts are currently reporting an unacceptable number of patients still waiting more than a year for treatment after referral.
At the end of September 2011, five trusts were responsible for around half of those people still waiting more than a year for treatment (see figure 12). These trusts, and any other trusts that are reporting patients still waiting more than a year for treatment after referral, must take action to understand the reasons behind these long waits and treat any patients still waiting as quickly as possible.
Amen to all that.
Which brings us to the latest big publication, which in many ways is the most important. The NHS Standard Contract lays out in detail the precise targets and penalties under which the NHS will operate in the coming financial year. Now that the Government has shown that it both understands the problems created by the old waiting time targets, and has shown willingness to change its approach in helpful ways, I would have expected the new Contract to:
- pay lip service to the old treatment-based targets and the regulations underpinning them around the NHS Constitution, but
- remove the financial penalties that actually punished Trusts for treating too many long-waiting patients, and
- replace them with a new penalty regime that punished Trusts for having too many long-waiters on the waiting list, in line with the new target.
(I’m not saying that creating a new penalty regime is necessarily the best way of going about this, just that it would be in keeping with the traditions of NHS management.)
So what does the Contract actually say? Here are the relevant paragraphs in all their glory (my emphasis below):
Subject to Clause 43.6, if in any month the Provider underachieves the 18 Weeks Referral-to-Treatment Standard threshold set out in Section B Part 8.2 (Nationally Specified Events) for any specialty, then the Commissioners shall deduct for each such specialty an amount calculated in accordance with Section B Part 8.4 and weighted in accordance with Clause 43.5, from any payments to be made to the Provider under this Agreement.
2012/13 NHS Standard Contract, Section E, clause 43.4
Technical Guidance Reference: PHQ19-20
Nationally Specified Event: Percentage of patients seen within 18 weeks in respect of Consultant-led Services to which the 19 Weeks Referral-To-Treatment Standard applies
Threshold: For admitted 90% and over And For non-admitted 95% and over
Method of Measurement: Review of monthly report under Clause 39.1 of the Core Legal Clauses
Consequence per breach: As set out in Clause 43.4 of the Core Legal Clauses and Section B Part 8.4
2012/13 NHS Standard Contract, Section B, Part 8.2 on p.16
Percentage by which the Provider underachieves the 18 Weeks Referral-to-Treatment Standard threshold set out in Section B Part 8.2 for each specialty (in respect of Consultant-led Services to which the 18 Weeks Referral-to-Treatment Standard applies) [heads a table column, with bands running from 0 to over 10 per cent]
Percentage of the revenue, derived from the provision of the (underachieved) specialty in the month of the underachievement, to be deducted under Clause 43.4 subject to the cap of 5% of the Contract Month Elective Care 18 Weeks Revenue pursuant to Clause 43.6 of the Core Legal Clauses [heads a column with penalties running from 0.5 to 5 per cent]
2012/13 NHS Standard Contract, Section B, Part 8.4 on p.26
Lots about the old admitted and non-admitted targets, then. But where is the incomplete pathways target? Nowhere.
What will this do to waiting times? It fundamentally undermines the Government’s stated intention to reduce the number of patients “forgotten” on English waiting lists. For all the Government’s fine words, the new Contract retains the penalties that punish Trusts for treating lots of long-waiting patients, and creates no new incentives for them to achieve short waits on the waiting list.
When money is tight, and Trusts have a statutory duty to balance the books, which of fine exhortations and financial penalties is going to weigh more heavily on peoples’ minds? (That was a rhetorical question.)
Personally, I am baffled. Why did the Department of Health not carry the new target through from the Operating Framework to the Contract? I simply do not understand it.
So here’s a little suggestion to DH. While you are correcting the typo that refers to a 19-week target, why not take this opportunity to change the penalty regime over to “92 per cent of incomplete pathways within 18 weeks”? If everyone’s off over Christmas, I’ll even help with the drafting.
Have a lovely festive break.
[Update: The NHS Standard Contract, Section B, Part 8.2 was amended by DH a few hours after this post was first published at HSJ blogs. They fixed the 19 week typo, but not the target.]
Doing surgery? Then you need anaesthetics on-site. Obstetrics? Then you need paediatrics.
Acute care is a tangled web of interdependent services, joined by so-called “clinical linkages”. Pull out something innocuous-looking, such as physiotherapy, and the whole thing collapses.
These clinical linkages were all mapped out in an earlier post, and Roy Lilley picked it up in his discussion about competition and regulation (as did Paul Leake). His argument was that competition in healthcare provision could lead to these clinical linkages being unpicked, with disastrous results; therefore any local service reconfigurations would need to be managed (and not left to the forces of competition) in order to preserve these clinical linkages.
So how real is this threat?
Let’s start by sketching out the scenario we are worried about. A healthcare provider (it doesn’t really matter if they are NHS or private) sets up a new elective facility, which attracts work away from the neighbouring NHS acute hospital. This destabilises the NHS hospital and triggers the closure of its acute services (including A&E), much unhappiness for local people, and a political row.
There are three possible ways in which the new provider could destabilise the old:
- by financial cherry-picking: diverting away from the old provider a lot of highly-profitable elective work that had been subsidising the loss-making clinically-linked acute services;
- by deskilling: diverting away a lot of elective activity, so that clinicians at the old provider are no longer seeing a big enough caseload and become deskilled, so that those clinicians can no longer provide a safe acute service on which other acute services depend;
- by poaching: recruiting clinicians away from the old provider, causing the closure of a service on which other acute services depend.
In the Parliamentary committee debates on the Health and Social Care Bill, there was quite a lot of discussion of the problems that might be caused by “cherry-picking”. Monitor responded to these concerns in two ways: firstly to point out that if the problem is that elective procedures are more profitable than non-elective ones, then the solution is to change the tariff price and remove the distortion; and secondly that if economic destabilisation of acute services is the possible result, then Monitor can designate those services as essential and allow extra funding for them.
I would add a further point: it would be rash to assume that elective care is always profitable and acute care is always loss-making. So much in healthcare is characterised by gross and unexplained variations, and so there are likely to be many highly-profitable acute non-elective services, just as there will be many highly-loss-making elective services.
Deskilling is more pernicious, and would not be solved by flinging money at designated services. If surgeons are twiddling their thumbs all day because their elective workload has disappeared down the road, they are not going to be as practiced when surgical emergencies come in. Recruitment and retention would also go to pot. If you lose acute surgery, then acute medicine is at risk and so is A&E. What can be done?
Well, the first question to ask is: where is the new provider going to get its doctors from? In the middle of London, it is quite possible to run a hernia factory from 9-5, Monday to Friday, keep a whole team of surgeons busy, and still leave plenty of elective work around for the rest of London’s NHS doctors; deskilling would not happen in that scenario. But could you do the same in Northampton or Stoke? In practice, you’d probably be using the same NHS doctors who work at the local NHS hospitals, and so they wouldn’t be deskilled, just maintaining their skills on a different hospital site.
For the sake of argument, though, let’s say you did manage to set up an elective factory in the shires without using doctors from the local NHS. Perhaps your medical staff have been brought back from retirement, or want to work family-friendly hours. Would that not pose a threat to the local NHS hospital? Indeed it might. But how might the NHS hospital respond? They could do nothing, and let their surgeons twiddle their thumbs on full pay, but that would be perverse. A more sensible response would be to make their surgeons available to the new provider on attractive enough terms, which sidesteps the deskilling problem and replaces lost income. So it looks as if the old provider could respond to the deskilling threat, and head it off.
What about the third threat: poaching? Well the short answer is that nobody is irreplaceable. The old hospital can just recruit some new doctors. And if the service is so unattractive that it is impossible to recruit, then the old hospital’s problems run much deeper than the arrival of a new elective provider.
So we have seen how a degree of flexibility by the old provider can help sidestep the threat of destabilisation by the new. But we have tacitly assumed in this scenario that both the new and old providers are traditional monoliths who operate hospital buildings, and employ clinical staff, and contract with the NHS commissioners.
Now let’s imagine a world in which those three functions are unbundled. One possible way of doing this would be for the doctors in the old NHS hospital to establish themselves as Chambers and contract directly with commissioners; then the Chambers pays the hospital for the buildings, nurses, diagnostics and so on. Now we can see how much easier it would be to avoid the deskilling problem, which was the most serious challenge we faced above.
Because each Chambers could work across multiple hospital sites, it could respond much more flexibly than a traditional hospital service that was anchored to its buildings. If deskilling ever became an issue, the Chambers could redeploy clinicians across different hospital sites to head off the problem. It could, for instance, supply the clinicians needed by the new provider, including (where it made sense) retired or family-committed doctors.
So it is far from clear that clinical linkages are necessarily threatened by competition in healthcare provision. And even if they are, a flexible and competitive provider market could respond by unbundling provider functions in a way that unties people from buildings.
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.
Hospitals accepting unselected medical emergencies must have on-site surgery.
There’s a lot of guidance like this, from the Royal Colleges, subspecialist societies, NCEPOD, and the Department of Health, all describing in helpful detail the critical links that exist between different acute services.
But each document describes only a few strands in a complex web of interdependencies. Senior clinicians and managers, however, need a system-wide view, but it is difficult to piece together the whole picture from this mass of detail.
The lack of a big picture can waste a lot of time. When acute reconfigurations are being considered, managers and clinicians may get together in a large group to draw up the reconfiguration options. Much later, after a lot of work, some options have to be struck out when a fatal flaw is discovered (such as not being able to separate paediatrics from obstetrics). At worst the lack of a big picture can be dangerous, when piecemeal changes are made locally, to individual services, without realising that they could destabilise the whole hospital.
So we need an overview of these important clinical linkages. Looking only at those 24-hour services that must be provided on the same hospital site, we think the links look something like this. A solid line means that one service must support the service it points to; a dotted line means that it is possible to run the service without that support but procedures must be in place to ensure safety.
There are caveats of course. It isn’t possible to capture all the nuances of this complex guidance in one diagram: for instance, the distinction between a selected and unselected acute medical take is not fully captured. Also there are cases where older guidance states a requirement that is not mentioned in more recent, overlapping guidance; this leaves it unclear whether the requirement has been softened. In the full version of this work, therefore, the diagram is accompanied by the relevant passages from the guidance (referenced by the numbers beside the arrows).
We think this is the first time that acute clinical linkages have been comprehensively published in this way. At a time when acute hospitals and commissioners are under pressure from the EWTD and the financial squeeze, many are considering whether they could transfer services to an adjacent hospital or stop providing them altogether. This map of acute interdependencies should help to show where this can, and cannot, be done safely.
To take just one example, could you save money by downgrading physiotherapy to daytime only? A novice manager might think so. But the answer is clearly no, because that would put at risk the intensive care unit, acute surgery and medicine, and the A&E department. Not a career-enhancing move.
We ended the previous post with our Challenged Trust looking at its money quite differently. Instead of squeezing the biggest-spending budgets in time-honoured fashion, we now know which services are profitable and which are loss-making, which means we can focus on turning our loss-makers around without hurting our profit-centres. We also know the price of each theatre minute, bed day, X-ray and so on, making it much easier to spot things that look expensive (£1,300 for an ophthalmology inpatient bed day? £400 for a histology test?).
In effect, we have turned our organisation upside down.
Now we can see our income coming in at patient level, and our expenditure going out at patient level too. We can see how every part of the hospital is trading, not just with commissioners, but with every other part of the hospital too. Consultants are starting to wonder things like “if theatre time costs £25/minute, why are we wasting all that money by starting half an hour late every morning?”, and “why is the recovery room fully-staffed first thing, when the first patient never comes out of theatre before 9:45am?”.
These are good questions. If it was their money, they wouldn’t spend it like that. Suddenly they’re noticing a hundred details about the way they work that don’t make sense. But they still aren’t doing anything about it. Why? Because decades of experience has told them it isn’t worth the effort. But if it was their money…
Up in the management offices, we know we’re still struggling to turn our hospital around, to get it into good enough financial shape to be a Foundation Trust. Big organisations like this don’t go from awkward to nimble just like that. In a hospital, managers can’t implement change like we could in a factory. The Trust is full of autonomous professionals: medical consultants, nurse consultants, consultant scientists; they all have their own ways of doing things, and a fair bit of power to do it that way if they want. That’s a good thing, but it is also why change can be so grindingly slow, and often expensive if you have to lubricate the wheels of change with extra money. But time and money are the very things we don’t have.
It’s an old joke that a hospital would be a doddle to manage if it weren’t for the patients. But seriously, it would also be easier if it weren’t for the consultants. We could be running a superb Trust within months if our remit was to manage all the staffed facilities, including most of the nurses, but minus the consultants. Now that our newly-improved accounting has turned our organisation upside down, we can see a way of making that vision reality.
So we could have the GP commissioners buying orthopaedics directly from the orthopaedic surgeons, medicine from the physicians, and so on. The doctors could carry on working here as usual, and buy the theatre time and bed space and diagnostics from us. We could get on with running a great Foundation Trust with a large estate and thousands of staff, and they could get on with delivering the standard of care that GP commissioners expect, and using our facilities as efficiently as they can.
Working like that, it surely won’t be long before 9:01am is considered a “late start” in theatres. Who knows, we might even see anaesthetists wheeling the patients down themselves…
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.
At the end of July the NHS Chief Executive wrote round with the new Service Reconfiguration rules. His letter formalises the four straightforward tests that the new Secretary of State wants applied to every proposed service reconfiguration:
- support from GP commissioners;
- strengthened public and patient engagement;
- clarity on the clinical evidence base; and
- consistency with current and prospective patient choice.
Unfortunately the straightforwardness ends there, and the letter immediately runs into the heaped sands of inherited bureaucracy. The four tests involve commissioners, the public, patients, and (tacitly) the providers concerned, so it is unsurprising that these feature prominently in the letter. You would expect there to be some other process, given the risk and money involved in reconfigurations, but is it really necessary for local commissioners to involve all of the following? In order of appearance in the letter the cast list is:
- Strategic Health Authorities (SHAs)
- Local Authorities (LAs)
- Local Involvement Networks (LINks)
- Office of Government Commerce (OGC) Gateway
- National Clinical Advisory Team (NCAT)
- Independent Reconfiguration Panel (IRP)
- LA Health Overview and Scrutiny Committees (HOSCs)
- Cooperation and Competition Panel (CCP)
The involvement of so many bodies invites a number of criticisms. It is centralising and weakens local decision-making. It delegates complex judgements to bodies who may be expert in their subject but unfamiliar with the local particulars. It causes delay. It confuses the process, and thereby pushes blame back up the system to the Secretary of State. It is expensive.
So expect further reform, as the Coalition Government sets to work simplifying and localising decision-making in the NHS.
Something else is odd, though, and this goes to the heart of the Secretary of State’s new approach. The covering letter says:
The Secretary of State has also made it very clear that GP commissioners will lead local change in the future.
If the Secretary of State wants a market in healthcare, then surely this is going in the wrong direction? In a normal market, customers don’t design products; companies do. So healthcare providers should conduct the market research and consult the stakeholders, and if that goes well then they can design and take the business risk on developing new service configurations.
To be fair, the Secretary of State only walked into his office a few weeks ago, and cannot be expected to reform everything all at once. But, as the evolving policy on service reconfiguration shows, he will have his work cut out to achieve more straightforward and local decision-making in the NHS.
On Friday the Department of Health updated the Procurement guide for commissioners of NHS-funded services. It is littered with the familiar dreary life-sapping injunctions about OJEU notices, procurement rules, and the need to review, benchmark, and consult with everybody in sight. But in the middle of it all, you can glimpse the future of NHS commissioning: the Any Willing Provider (AWP) model. The guidance says:
AWP may be described as an accreditation process underpinned by a ‘call-off’ contract (ie payment is determined according to patients’ choice of provider). AWP has been defined nationally in its application to routine elective care, but can be adapted locally to facilitate patient choice in other services.
…which of course is virtually identical to the wording in the March 2010 version, and a continuation of the AWP rules that were set back in May 2008. So far, the “Liberative” policy is identical to the “New Labour” one.
As often happens with policy innovations, the AWP model is aimed at routine elective care. Policy-makers don’t like messing with the hot stuff if there is a less-controversial area they can start in. But they did leave the door ajar for AWP to be used in other areas of healthcare as well, if local commissioners want to stick their necks out. And local commissioners should. The language in the guidance may be couched around patient choice, but it works for commissioner choice too and gives GP commissioners much greater flexibility when referring emergencies and electives alike.
The trouble with AWP is that it insists on using the NHS Standard Contract, which itself is still rooted in the old world of planning and performance management. What AWP really needs is a Standard Contract Lite, under which GP practices could refer at tariff or local prices but without needing to go through the laborious processes for agreeing detailed activity tables and performance indicators.
That would bring GP Commissioning closer to the world of the normal small business. A local firm of plumbers does not negotiate and agree lengthy annual contracts with each of its suppliers, specifying guaranteed volumes and bespoke performance standards. Instead it sets up accounts at Travis Perkins, Plumb Center and the rest, and pops in from time to time for pipes, valves and whatever else it needs. If one supplier disappoints on cost or quality, they favour a different one for a while. Minimum performance is taken care of by law, regulation, and standards.
Healthcare is more complex and expensive than plumbing, but in other respects the analogy holds where there is a choice of provider. In this spirit, the Procurement guide says for AWP:
As a minimum, potential providers must demonstrate that:
1) They are registered with CQC (or other relevant body) for that service
2) They agree to the tariff that commissioners are willing to pay
3) They receive no guarantees of volume / payment
So minimum standards are assured, price is fixed, and the activity plan tables in the Standard Contract are redundant. This should make the development of a Standard Contract Lite relatively straightforward; all that is needed is a minimum-content default wording for all the locally-negotiated elements in the contract (which in most cases will simply state “Not used”). Local commissioners could do this themselves, or the Department could save them the trouble by providing default wording for them.
Is that it? When Standard Contract Lites are in place for AWPs, can GPs buy care for their patients just as any small business manages its supplies? Not quite: there is still quite a lot of other baggage to deal with. Can you imagine an average GP being enthused about commissioning, while:
In addition, this guidance requires that commissioners also undertake the following as part of the procurement decision-making process
- Undertake Service reviews to identify areas for improvement and ensure alignment with commissioning strategy (eg QIPP)
- Apply benchmarking to existing services
- Use healthcare market analysis
- Specify relevant service specification, outcomes, KPIs and expected prices
- Engage early with providers, staff and representatives / Trades Unions to asses the potential impact / deliverability of the service
- Engage with service users local communities and other key stakeholders eg Health Overview Scrutiny Committees and successor arrangements …
- Have regard to any sustainable development aspects of the procurement.
This baggage had its place in large-scale bureaucratic commissioning. But it will be unsuited and unnecessary in a more normal marketplace, in which the real commissioners are referring GPs, and the risk of establishing a service lies firmly with the provider. When PCTs are leaving the stage, would they kindly remember to bring all their baggage with them?