Practice based commissioning in the UK

An editorial in the BMJ a year ago asked whether practice based commissioning was “the sick man of the NHS reforms.”1 Practice based commissioning has been a central part of the government’s health policy since April 2005, when interested practices were first entitled to indicative budgets. The paucity of achievements described in a recent assessment by the King’s Fund suggests that the health of this patient is little improved.2 The government has recently clarified its vision for practice based commissioning, but will this be enough to deal with its persistent weaknesses?3

Commissioning is a mechanism for managing financial risk while matching services supplied to patients needs (or demands) in a quasi-market where patients do not pay for services directly. However, nearly two decades of experimentation in the English NHS have provided little evidence that any form of commissioning has greatly affected hospital services. Commissioning led by primary care has delivered some benefits in primary and intermediate care and some improvements in the responsiveness of elective hospital care, but are they sufficient to justify its continued existence?4 5

Primary care commissioning capitalises on the pivotal role of general practitioners as “gatekeepers” to hospital services and their supposed knowledge of local services. Budgetary responsibilities were aligned with clinical decision making when the prototype, general practitioner fundholding, was introduced in 1990.6 Fundholding harnessed the entrepreneurial flair of general practitioners through financial incentives to reduce unnecessary use of care, promote new community based services, and negotiate lower prices for and faster access to hospital treatment. Over time, concerns about the inequitable nature of fundholding and its high transaction costs led to the evolution of more collective forms of primary care commissioning.

The King’s Fund researchers undertook wide ranging interviews within four primary care trusts, and their findings echo those of an earlier report from the Audit Commission.7 Practice based commissioning is stalling—a view that is implicitly acknowledged by the government in Lord Darzi’s review last summer.8

Collaborative working between practices and their local primary care trusts has improved, but signs of service development remain few—although they have recently increased.9 Of course, practice based commissioning is a work in progress, and advances may be imminent. On the other hand, the King’s Fund’s report may underestimate many factors that weaken interest in practice based commissioning. For practices, the absence of strong incentives in the face of increasing financial insecurity means that the imperatives of the quality and outcomes framework may take priority. For primary care trusts, the latest developmental preoccupation is “world class commissioning,” a multifaceted programme intended to increase their strategic effectiveness,10 which is diverting their interest, in the short term at least, from supporting practice consortiums.

However, all manifestations of primary care commissioning have been beset by common weaknesses. These include a lack of clinical engagement, organisational immaturity, insufficient support from management, limited public involvement or accountability, and lack of information on which to base commissioning decisions.11 The right formula with which to tackle these weaknesses remains, as yet, stubbornly out of reach. This raises the question of whether these deficits are simply intrinsic.

So where do we go from here? The King’s Fund team is judiciously pragmatic and proposes a “matrix” model that recognises the multilayered nature of commissioning and places different responsibilities at different levels. This would give general practitioners real budgets while retaining population wide commissioning with primary care trusts. Other “solutions” abound. The Royal College of General Practitioners’ proposal for practice federations (associations of practices and community primary care teams—for example, in the form of a social enterprise or limited company—that aim to develop health services) may provide much needed critical mass and the ability to develop expertise.12 There may be a role for general practitioners with a special interest in public health and commissioning to strengthen management capacity.13

New “integrated care organisations” are about to be piloted.14 These will offer real budgets to practices in return for the responsibility to manage health and population care by providing or commissioning new service models that unify primary care, community care, social care, and some forms of secondary care. Integrated care organisations offer the prospect of much stronger incentives for general practitioners and other professionals to shape local services.

Practice based commissioning is clearly not about to be dismantled, even with a change of government, but its next iteration needs to deliver more. The Department of Health has reconfirmed its commitment to practice based commissioning and has clarified practices’ entitlements to timely information, management support, local incentives, and rapid decision making by primary care trusts. An investment of £1m (€1.1m; $1.4) has been made to pump prime practical support for practice based commissioners and their primary care trusts. These initiatives are a welcome starting point. But if tangible results remain elusive, evidence based policy makers will wonder whether this patient needs palliative care not reinvigoration.